Based on resident interview, staff interviews, facility documentation and the facility's policy, the facility staff failed to ensure the correct mechanical transfer device was used to prevent avoidable pain/injury for one (1) out of three (3) residents (Resident #1) in the survey sample. The findings included: Resident #1 was originally admitted to the nursing facility on 06/07/22. Diagnosis for Resident #1 included but are not limited to chronic pain, weakness, and restless leg syndrome (RLS.) The most recent Minimum Data Set (MDS - an assessment protocol) an annual assessment with an Assessment Reference Date (ARD) coded the resident's Brief Interview for Mental Status (BIMS) scored 15 of a possible 15 with no impairment for daily decision-making. In section G (Physical functioning) the MDS coded Resident #1 required total dependence of two with transfer, total dependence of one with toilet use, and bathing, extensive assistance of one with bed mobility, personal hygiene and dressing and supervision with limited assistance of one with eating for Activities of Daily Living (ADL) care. Resident #1's care plan created on 06/14/22 identified the resident has potential for health and safety concerns related to ADL needs and mobility. The goal set for the resident by the staff was to maintain safety through appropriate assistance and safety measures. Some of the interventions/approaches the staff would use to accomplish this goal was to provide transfer assistance when transferring to and from different surfaces and total lift attended by at least two (2) staff members. A review of Resident #1's Certified Nursing Assistant (CNA) current worksheet indicated the resident required a total lift transfer with two (2) assist. An interview was conducted with the Department Head of Rehab on 06/13/23 at 12:30 p.m. She stated Resident #1 was a total assist of two (2) with the use of a full mechanical lift for all transfers. She stated the Hoyer lift was the safety mode of transfer for Resident #1 due to the resident's inability to bear weight. She stated to use the sit/stand lift, the resident must be able to bear weight on hold on to the grip bars as instructed, something Resident #1 is unable to perform. On 06/13/23 at approximately 1:20 p.m., an interview was conducted with Resident #1. She stated on 03/11/23, CNA #1 transferred her using a full mechanical lift (Hoyer-brand name) without the assistance of another staff member to the shower chair. She stated after she was in the shower chair, she had an incontinent episode and the CNA used the sit/stand lift to raise me from a sitting to a standing position. She stated she is not able to bear weight or hold on, so the sit/stand lift does not work for her. She stated the CNA hooked her up to the lift and once the lift started to raise her body from a sitting to a standing position, she experienced pain to her lower back. She stated she yelled for CNA #2 who came into the room after she heard me yelling. She stated the CNA could have cause more harm than just causing back pain. CNA #2 was interviewed on 06/13/23 at 1:37 p.m., who stated she heard Resident #1 yelling her name. She stated she went to the Resident #1's room and observed the resident sitting on a shower chair while hooked up to the sit/stand lift. She stated CNA #1 had used the sit/stand lift machine on Resident #1 who is to be transferred only using the Hoyer lift with two (2) assists. She stated the resident informed her when the CNA used the sit/stand lift, it hurt her back. The CNA stated she immediately reported the incident to the Charge Nurse. On 06/13/23 at 1:55 p.m., an interview was conducted with Charge Nurse (LPN #1) She stated when she walked into Resident #1's room, the resident was still sitting on the shower chair connected to the sit/stand lift. She stated CNA #1 should have never used the sit/stand lift on Resident #1 because she is unable to bear weight. She stated Resident #1 is a Hoyer lift transfer only with the use assistance of two (2) people. She stated Resident #1 complained of lower back pain. The resident was administered her scheduled pain medication (Hydrocodone 5 mg) with effective results. She stated no further pain medication was needed. On 06/13/23 at 2:09 p.m., an interview was conducted with the Assistant Director of Nursing (ADON) who stated she received a phone call from the Charge Nurse (LPN #1) who stated CNA #1 transferred Resident #1 incorrectly. She stated the CNA used the sit/stand lift on the resident instead of the Hoyer lift. On 06/14/23 at 2:14 p.m., the Administrator, Director of Nursing, Assistant Director of Nursing, Director of Clinical Support were informed of the above findings. The Director of Clinical Support stated the sit/stand machine should have never been used on Resident #1 due to weakness in her bilateral lower extremities. She stated when the CNA used the Hoyer lift to transfer the resident, there should have been two (2) people, one to operate the machine and the other person to guide/supervisor the resident during the transfer. She stated the purpose of using 2 people during the transfer is to maintain their safety. The facility's policy titled Mechanical Lifts revised on 03/23/15. The mechanical lift is used on residents who are unable to safely transfer independent or with a gait belt. -Sit to Sand Lift: The resident should be able to bear weight (even if only on one side). If the resident is unable to bear weight the total lift should be used. -Total Lift: (Horizontal lifting from bed or floor) requires at least two (2) people are required for transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, self reported documentation, family and staff interviews, the facility staff failed to ensure one resident (Resident #41) was free from physical abuse to include having a bruise on her right lower extremity and failed to protect one resident, Resident #99 who was reviewed for neglect, in the survey sample of 39 residents. The findings included: 1. Resident #41 was admitted to the facility on [DATE] from an acute care facility with a diagnosis of Alzheimer's disease with late onset and Major Depressive Disorder. The annual, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/02/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long- and short-term memory problems as well as severely impaired for daily decision making. Resident #41 requires total dependence of one person with dressing, grooming, eating, toileting, and personal hygiene, requires and bathing. The care plan dated 11/29/17 indicated: Focus-Resident is totally dependent on staff for all ADLs (Activity of Daily Living). Goal-Resident will have personal hygiene needs met and be transferred safely without injury. Interventions: assist her to turn/reposition in bed frequently mechanical lift for transfers personal hygiene done by staff usually has 2- 1/2 bedrails up. The self reported documentation dated 11/14/22 indicated Resident #15 wandered into Resident #41's room and during attempts to re-direct Resident #15, she became combative and forcefully grabbed Resident $41's right leg causing a bruise. On 11/21/22 a final plan to address the wandering behaviors of Resident #15 included programming development for her cognitive impairments and to work toward finding placement to be near her son. Additional training in addressing combative behaviors, redirecting residents with these behaviors in a manner to avoid escalting agitation. Discusssions during the Quality Assurance Committee Monthly meeting would address trends and patterns with corrective action plans implemented or revised if applicable. A review of clinical records: A nursing note dated 11/12/22 at 4:15 AM., indicated that Resident #15 was wondering into Resident #41's room and found lying in bed and became combative when the CNA (Certified Nurse's Aide) attempted to remove her. She grabbed Resident #41 legs and refused to let go. There are no injuries to report at this time. CNA and writer able to remove her out and place her back into her room. 11/12/22 at 11:58 AM., indicated: Discoloration noted to the lower extremities. Long Term Care aware. Representative aware. A nursing note dated 11/13/22 at 11:49 AM. Indicated that the nurse notified the NP (Nurse Practitioner) for something for agitation and behavior. Trazodone as needed was only for 14 days. The clinical notes dated 11/14/22 at 10:22 AM. Read: X-ray done as ordered, results show no fractures, no evidence of dislocation. no acute abnormality is seen. Results fax to provider. A nursing note dated 11/14/22 at 12:03 AM., indicated Resident #15 was up wandering off the unit into another resident's room she was redirected back to her room drink and snack accepted bed alarm place under nursing interventions to monitor movement. She is in bed resting at this time bed in lowest position will continue to monitor call light and fluids are in reach. This occurred after the event on 11/12/22. Behavior monitoring notes in the clinical records reads: Refer to Behavior Monitoring Sheet for 11/15/22, 11/16/22 and 11/17/22. Behavior Monitoring Sheets were not available. A nursing note dated 11/18/22 at 5:21 AM., indicated that Resident #15 was rested throughout this shift, no behaviors noted at this time will continue monitoring checks. A nursing note dated 11/22/22 at 11:44 AM., indicated Resident #15 was transferred to another facility. On 11/30/22 at approximately 12:11 PM., an interview was conducted with the resident's daughter concerning the incident. Resident #41 was observed resting quietly in her bed with her daughter and son at her bedside. The resident's daughter pulled back the blanket revealing a bluish discoloration about 1 inch in length below her right lower extremity knee. She said that her mother's Right lower leg was still bruised on 11/14/22, two days after the incident occurred. She also said that due to her mom having thin skin she bruises easily. On 12/01/22 at approximately 1:00 PM an interview was conducted with the DON (Director of Nursing) concerning the above incident. The DON said that the incident occurred on 11/12/22 at 4:07 AM. but was not brought to her attention until 11/14/22 by the resident's (Resident #41) daughter. She completed a FRI. Initially when I saw the resident, I called the administrator. They went to the resident's bedside and the daughter showed them the pictures of the bruise on the resident's right leg. I initiated a FRI. She said that the nurse said that she forgot to put her note in. The DON also said that they should have reported this incident in 2 hours. No changes with her (Resident #15) medications but she appeared more confused. Her norm was not going into other people rooms. She was not re-directable, so she grabbed onto Resident #41's right leg. They started the investigation on 11/14/22 and the DON did see a bruise on the resident's leg. She also said that a note was put in Resident #15's chart of her going into Resident #41's room. She said that the outcome of the FRI was that the resident was sent to another facility that had a memory care unit. Her daughter said that she was okay with the transfer. The perpetrator, Resident #15 was admitted to the facility on [DATE]. Her admitting diagnosis includes Schizophrenia, Dementia and Bipolar Disorder. The quarterly revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/08/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #15 cognitive abilities for daily decision making were severely impaired. Resident #15 requires extensive assistance of one person with dressing, bed mobility, limited assistance of one person with locomotion on and off the unit, transfers, walking on the unit, walking in the corridor on the unit and personal hygiene, requires supervision set-up help only with eating, requires total dependence of one person with bathing. The Policy: Health Services will develop and implement policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, mistreatment, neglect, exploitation, and misappropriation of resident's property. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrence of resident abuse. Definitions: Abuse-Is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Abuse also concludes the deprivation by an individual. Including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Mistreatment means inappropriate treatment or exploitation of a resident. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Identification-Staff are encouraged to identify, correct and intervene in situations in which abuse, neglect is likely to occur. Protection: In the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and resident representative, and protect the resident from other residents from further harm or incident. No written statements from the staff were provided. On 12/01/22 at approximately 3:15 pm a telephone interview was conducted with Resident #15's family member concerning her transfer to another facility. She said that she was okay with the family member being transferred to a memory care unit at another facility. On 12/01/22 at approximately 8:00 p.m., a pre-exit interview was conducted with the administrator, the DON, and the Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. At the conclusion of survey, prior to survey exit, no further documentation was presented. 2. The facility failed to protect one resident Resident (R) (99) reviewed for neglect. Review of the facility's policy titled, Resident Abuse Policy and Procedure, dated 11/07/22 revealed, It is the policy of this facility to ensure the resident will be free from . neglect, During an interview with R99 on 11/30/22 at 9:12 AM, R99 stated that he had been dropped from the mechanical lift last summer. He stated he had told Certified Nurse Aide (CNA) 2 to stop because it did not feel right while he was in the mechanical lift. R99 stated, I said this isn't going to work. I wasn't secure to begin with. I told her to stop, and I jerked, and she just kept on. R99 stated CNA 2 did not stop and continued with the transfer. R99 stated, since the fall, something changed inside me. He stated he had more discomfort and pain since the fall. He stated it felt disrespectful that management had not talked with him about the fall until a week after the fall had occurred. During an interview with R99, on 12/01/22 at 9:51 AM, R99 stated he trusted some of the staff that assisted him with transfers. He stated that he did not feel anxious anymore and was glad CNA 2 had transferred to another unit. Review of R99's Face Sheet located in the electronic medical record (EMR) under the Resident Profile tab, revealed an admission date of 02/25/22 with medical diagnoses of Quadriplegia and Anxiety Disorder. Review of R99's quarterly Minimum Data Set (MDS) located in the EMR under the RAI tab with an Assessment Reference Date (ARD) of 10 /21/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R99 was cognitively intact. The MDS revealed R99 required total assistance from staff for all activities of daily living (ADL). Review of the Progress Note dated 06/10/22 found in the EMR under the Resident Profile, tab, signed by the Nurse Practitioner revealed, I found [R99] to be laying on the floor under the Hoyer lift with his head on the bottom leg of the lift. He had the Hoyer sling partially underneath him. He was awake, alert and very shaken by the incident. Staff assisted him back to bed. He states that he hit the back of his head on the metal leg of the lift. He tells me that I tried to tell them that it was not hooked up right. He tells me that when he fell, he was in the sling at approximately the level of his bed. It is unclear exactly what happened. Review of the event report dated 06/10/22, revealed R99 fell on [DATE] at 12:30 PM and revealed R99 had Swelling left low back of head and mid low back of head. The incident report revealed R99 Slipped from pad. Review of the Statement Form dated 06/10/22, signed by CNA2 revealed, At 12:30 PM I was helping [CNA 3] putting [R99] back to bed he slide [sic] out of the pad unto the lift he hitted [sic] the legs I called for nurses to looked [sic] at him. Review of the Statement Form dated 06/10/22, signed by CNA3, revealed I went in room around 12:30 [PM] to give [R99] a bath. [CNA2] came in and said [R99] wanted to go to bed. She help [sic] me put him to bed. We were connecting the Hoyer lift (Mechanical Lift) pad to the Hoyer lift and started lifting him when he first got lifted in the air, I heard the Hoyer lift snap like it was about to fall but the recliner chair was still behind him. [CNA2] was still lifting the Hoyer lift and she told me to lower the bed. In the middle of me lifting the bed [R99] said he feel [sic] like he falling [sic] next thing you know he fell and hit his head on the Hoyer lift. Review of the Statement Form dated 06/16/22, signed by the Corporate Infection Preventionist nurse, revealed Resident interview after staff reporting [R99] wanted to speak to someone about concerns surrounding fall on 06/10/22 .[CNA2] did not listen to him when he told her it felt like the leg portion of the sling was not properly secured .He told [CNA2] please stop it feels like I'm slipping .[CNA2] was operating the lift controls. Review of Employee Counseling/Tracking Form found in CNA employee file, dated 06/17/22 (seven days after the fall and one day after the resident was interviewed), CNA 2 was suspended. The document revealed the employee was receiving counseling Failure to adhere to policy and procedure related to use of mechanical lift. Suggestions for improvement of performance included Ensure you are listening to resident verbal cues of discomfort of distress during transfer. The summary revealed Her [CNA 2] failure to follow procedure may result in injury to resident .Due to nature of the concern, [CNA 2] will be suspended for two days. Review of the Training Record, dated 07/06/22, revealed four staff had been trained on Correct application of sling with contracted resident. Paying attention to resident cues (verbal/nonverbal). Safe transfer technique-two staff members, position of resident, position of chair. During an interview with the DON, the [NAME] President of Nursing (VPN), and the Assistant Director of Nursing (ADON) 5 , on 11/30/22 at 4:27 PM, the DON stated that CNA 2 should have listened to the resident. The resident knows if there is a problem. The VPN stated that an abuse investigation had not been completed. During an interview with the Corporate Infection Preventionist nurse, on 11/30/22 at 4:50 PM, she confirmed she had interviewed R99 on 06/16/22 (six days after the fall). She stated the reason she had interviewed him was because staff kept hearing from him. She stated this was the first time the resident had been interviewed. During an interview with the Nurse Practitioner, on 12/01/22 at 4:39 PM, she stated, after R99 fell, she had seen the resident. She stated R99 told her, I tried to tell them that it was not hooked up right. The Nurse Practitioner stated that after R99 told her this, she had reported the information to staff. The facility self reported documentation on 11/30/22, revealed the event date of 06/10/22 as alleged neglect that indicated the resident was being transferred via a full mechanical lift and he told the CNA to stop the transfer because he felt he was sliiping from the sling. According to [R99] they did not stop, and he slipped from the sling. The action taken revealed The former DON talked with [R99], conducted an investigation and had staff in-serviced on proper transfer with the lifts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility self report documentation, family and staff interviews, the facility staff failed to implement their policies and procedures to report and investigate an abuse allegation involving two residents, Resident #41 and Resident #15 (the perpetrator), a closed record resident in the survey sample of 39 residents. The findings included: 1. For Resident #41 the facility staff failed to report and investigate a physical abuse allegation that resulted in the resident having a bruise on her right lower extremity to the Resident Representative, Administrator/ designee, APS (Adult Protective Services) or to the State certification and certification agency. The incident occurred on 11/12/22 but was not reported until 11/14/22. Resident #41 was admitted to the facility on [DATE] from an acute care facility with diagnosis Alzheimer's disease with late onset and Major Depressive Disorder. The annual, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/02/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long- and short-term memory problems as well as severely impaired for daily decision making. Resident #41 required total dependence of one person with dressing, grooming, eating, toileting, and personal hygiene, requires and bathing. The care plan dated 11/29/17 indicated: Focus-Resident is totally dependent on staff for all ADLs (Activity of Daily Living). Goal-Resident will have personal hygiene needs met and be transferred safely without injury. Interventions: assist her to turn/reposition in bed frequently mechanical lift for transfers personal hygiene done by staff usually has 2- 1/2 bedrails up. The self reported documentation was not initiated until two days after the event occurred on 11/14/22. The event occurred on 11/12/22. The residents involved included Resident #41 and Resident #15 (A Closed Record Resident). Injuries included a bruise below the right knee. The facility documented that the event was an allegation of abuse/mistreat. Resident #15 wandered into Resident #41's room and during attempts to re-direct Resident #15, she became combative and forcefully grabbed Resident $41's right leg causing a bruise. On 11/21/22, the five day final self reported documentation included to address the wandering behaviors of Resident #15 included programming development for her cognitive impairments and to work toward finding placement to be near her son. Additional training in addressing combative behaviors, redirecting residents with these behaviors in a manner to avoid escalating agitation. Discussions during the Quality Assurance Committee Monthly meeting would address trends and patterns with corrective action plans implemented or revised if applicable. The fax confirmation dated 11/14/22 revealed the initial self reported documentation of the aforementioned event, sent to the State survey and certification agency. The fax confirmation dated 11/21/22 revealed the final self reported documentation, sent to the State survey and certification agency. According to the abuse policy under Procedure: All alleged violations involving mistreatment, neglect, exploitation or abuse including injuries of an unknown source and misappropriation of residents property must be reported immediately to the administrator/designee of the facility. The facility Administrator or designee will then report by fax to the State survey and certification agency no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in bodily injury. Resident to Resident altercations will be investigated as a potential abuse situation. An incident of willful intent that inflicts injury or harm to a resident by another resident is considered abuse and will be reported to the State survey and certification agency and Adult Protective Services. A resident-to-resident suspected abuse will also be reported to law enforcement if appropriate. The facility must complete a thorough written investigation and must prevent further potential abuse while the investigation is in progress. A review of clinical records: 11/12/22 at 11:58 AM., indicated: Resident #41 had discoloration noted to the lower extremities. Long Term Care aware. Representative aware. A nursing note dated 11/12/22 at 4:15 AM., indicated that Resident #15 was wondering into Resident #41's room and found lying in bed and became combative when the CNA (Certified Nurse's Aide) attempted to remove her. She grabbed Resident #41 legs and refused to let go. There are no injuries to report at this time. CNA and writer able to remove her out and place her back into her room. A nursing note dated 11/13/22 at 11:49 AM. Indicated that the nurse notified the NP (Nurse Practitioner) for something for agitation and behavior. Trazodone as needed was only for 14 days. The clinical notes dated 11/14/22 at 10:22 AM. Read: X-ray done as ordered, results show no fractures, no evidence of dislocation. no acute abnormality is seen. Results fax to provider. A nursing note dated 11/14/22 at 12:03 AM., indicated Resident #15 was up wondering off the unit into another resident's room she was redirected back to her room drink and snack accepted bed alarm place under nursing interventions to monitor movement. She is in bed resting at this time bed in lowest position will continue to monitor call light and fluids are in reach. This occurred after the event on 11/12/22. A nursing note date 11/18/22 at 5:21 AM., indicated that Resident #15 was rested throughout this shift, no behaviors noted at this time will continue monitoring checks. Behavior monitoring notes in the clinical records reads: Refer to Behavior Monitoring Sheet for 11/15/22, 11/16/22 and 11/17/22. Behavior Monitoring Sheet not available. A nursing note dated 11/22/22 at 11:44 AM., indicated Resident #15 was transferred to another facility. On 11/30/22 at approximately 12:11 PM., an interview was conducted with Resident #41's daughter at the resident's bedside concerning the incident. Resident #41 was observed resting quietly in her bed with her daughter and son at her bedside. The resident's daughter pulled back the blanket and sheet on the resident revealing a bluish discoloration about 1 inch in length on her right lower extremity below the resident's knee. She said that her mother's Right lower leg was still bruised on 11/14/22, two days after the incident occurred. She also said that due to her mom having thin skin she bruises easily. 2. For Resident #15, the perpetrator, the facility staff failed to report an abuse allegation involving the perpetrator within a two-hour time frame. Resident #15 was admitted to the facility on [DATE]. Her admitting diagnosis includes Schizophrenia, Dementia and Bipolar Disorder. The quarterly revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/08/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #15 cognitive abilities for daily decision making were severely impaired. Resident #15 requires extensive assistance of one person with dressing, bed mobility, limited assistance of one person with locomotion on and off the unit, transfers, walking on the unit, walking in the corridor on the unit and personal hygiene, requires supervision set-up help only with eating, requires total dependence of one person with bathing. A nursing note dated 11/22/22 at 11:44 AM., indicated Resident #15 was transferred to another facility. On 12/01/22 at approximately 1:00 PM an interview was conducted with the DON (Director Of Nursing) concerning the above incident. The DON said that the incident occurred on 11/12/22 at 4:07 AM. but was not brought to her attention until 11/14/22 by the resident's (Resident #41) daughter. She completed a self reported document. She said, Initially when I saw the resident, I called the administrator. Then they went to the resident's bedside and the daughter showed them the pictures of the bruise on the resident's leg. She said that the nurse said that she forgot to put her note in. The DON said that they should have reported this incident in 2 hours. No changes with (Resident #15, the perpetrator) medications but she appeared more confused. Her norm was not going into other people rooms. She was not re-directable, so she grabbed onto Resident #41's right leg. She said they started the investigation on 11/14/22 and the DON said that she did see a bruise on the resident's leg. She also said that a note was put in Resident #15's chart of her going into Resident #41's room. She said that the outcome of the self reported investigation was that the resident was sent to another facility that had a memory care unit and that Resident #15's daughter said that she was okay with the transfer. On 12/01/22 at approximately 1:00 PM an interview was conducted with the DON (Director of Nursing) concerning the above incident. The DON said that the incident occurred on 11/12/22 at 4:07 AM. but was not brought to her attention until 11/14/22 by the resident's (Resident #41) daughter. She completed a self reported document. She said, Initially when I saw the resident, I called the administrator. She said that the nurse said that she forgot to put her note in. The DON said that they should have reported this incident in 2 hours. The Policy: Health Services will develop and implement policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, mistreatment, neglect, exploitation, and misappropriation of resident's property. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrence of resident abuse. Definitions: Abuse-Is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Abuse also concludes the deprivation by an individual. Including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Mistreatment means inappropriate treatment or exploitation of a resident. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Identification-Staff are encouraged to identify, correct and intervene in situations in which abuse, neglect is likely to occur. Protection: In the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and resident representative, and protect the resident from other residents from further harm or incident. On 12/01/22 received in-service training record dated 11/15/22 at 8:30 AM. Subject: Changes to Reporting Resident Abuse After October 24, 2022, and How to Approach A Dementia Patient, Dated: 11/17/2022. No written statements from the staff were provided at this time. On 12/01/22 at approximately 8:00 p.m., a pre-exit interview was conducted with the administrator, the DON, and the Corporate Consultant. The Administrator said that the staff had received inservice training in July and on November the 15th (2022) and the staff did not do what they were trained to do. At the conclusion of survey, no other documentation was presented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility self report document, family and staff interviews, the facility staff failed to ensure appropriate abuse training was implemented to include reporting an abuse allegation involving two residents, Resident #41 and Resident #15 (the perpetrator), a closed record resident, and they failed to timely report an allegation of neglect for one resident, Resident #99 in a survey sample of 39 residents. The findings included: 1. For Resident #41 the facility staff failed to report a physical abuse that resulted in resident having a bruise on her right lower extremity in a timely manner (Within 2 hours) that occurred on 11/12/22 until 11/14/22 . Resident #41 was admitted to the facility on [DATE] from an acute care facility with diagnosis Alzheimer's disease with late onset and Major Depressive Disorder. The annual, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/02/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long-and short-term memory problems as well as severely impaired for daily decision making. Resident #41 requires total dependence of one person with dressing, grooming, eating, toileting, and personal hygiene, requires and bathing. The care plan dated 11/29/17 indicated: Focus-Resident is totally dependent on staff for all ADLs (Activity of Daily Living). Goal-Resident will have personal hygiene needs met and be transferred safely without injury. Interventions: assist her to turn/reposition in bed frequently mechanical lift for transfers personal hygiene done by staff usually has 2- 1/2 bedrails up. The self reported documentation dated 11/14/22 indicated Resident #15 wandered into Resident #41 and during attempts to re-direct Resident #15, she became combative and forcefully grabbed Resident #41's right leg causing a bruise. On 11/21/22 the final report of the event indicated a plan to address the wandering behaviors of Resident #15 included programming development for her cognitive impairments and to work toward finding placement to be near her son. Additional training in addressing combative behaviors, redirecting residents with these behaviors in a manner to avoid escalating agitation. Discussions during the Quality Assurance Committee Monthly meeting would address trends and patterns with corrective action plans implemented or revised if applicable. The fax confirmation dated 11/14/22 revealed the initial self reported documentation of the aforementioned event, sent to the State survey and certification agency which was 2 days after the event. The event occurred on 11/12/22. The fax confirmation dated 11/21/22 revealed the final self reported investigation documentation of the event, sent to the State survey and certification agency. According to the abuse policy under Procedure: All alleged violations involving mistreatment, neglect, exploitation or abuse including injuries of an unknown source and misappropriation of residents property must be reported immediately to the administrator/designee of the facility. The facility Administrator or designee will then report by fax to the State survey and certification agency no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in bodily injury. Resident to Resident altercations will be investigated as a potential abuse situation. An incident of willful intent that inflicts injury or harm to a resident by another resident is considered abuse and will be reported to the State survey and certification agency and Adult Protective Services. A resident to resident suspected abuse will also be reported to law enforcement if appropriate. A review of clinical records: 11/12/22 at 11:58 AM., indicated: Resident #41 had discoloration noted to the lower extremities. Long Term Care aware. Representative aware. A nursing note dated 11/12/22 at 4:15 AM., indicated that Resident #15 was wondering into Resident #41's room and found lying in bed and became combative when the CNA (Certified Nurse's Aide) attempted to remove her. She grabbed Resident #41 legs and refused to let go. There are no injuries to report at this time. CNA and writer able to remove her out and place her back into her room. A nursing note dated 11/13/22 at 11:49 AM. Indicated that the nurse notified the NP (Nurse Practitioner) for something for agitation and behavior. Trazodone as needed was only for 14 days. The clinical notes dated 11/14/22 at 10:22 AM. Read: X-ray done as ordered, results show no fractures, no evidence of dislocation. no acute abnormality is seen. Results fax to provider. A nursing note dated 11/14/22 at 12:03 AM., indicated Resident #15 was up wondering off the unit into another resident's room she was redirected back to her room drink and snack accepted bed alarm place under nursing interventions to monitor movement. She is in bed resting at this time bed in lowest position will continue to monitor call light and fluids are in reach. This occurred after the event on 11/12/22. A nursing note date 11/18/22 at 5:21 AM., indicated that Resident #15 was rested throughout this shift, no behaviors noted at this time will continue monitoring checks. Behavior monitoring notes in the clinical records reads: Refer to Behavior Monitoring Sheet for 11/15/22, 11/16/22 and 11/17/22. Behavior Monitoring Sheet not available. A nursing note dated 11/22/22 at 11:44 AM., indicated Resident #15 was transferred to another facility. On 11/30/22 at approximately 12:11 PM., an interview was conducted with Resident #41's daughter at the resident's bedside concerning the incident. Resident #41 was observed resting quietly in her bed with her daughter and son at her bedside. The resident's daughter pulled back the blanket and sheet on the resident revealing a bluish discoloration about 1 inch in length on her right lower extremity below the resident's knee. She said that her mother's Right lower leg was still bruised on 11/14/22, two days after the incident occurred. She also said that due to her mom having thin skin she bruises easily. On 12/01/22 at approximately 1:00 PM an interview was conducted with the DON (Director Of Nursing) concerning the above incident. The DON said that the incident occurred on 11/12/22 at approximately 4:07 AM. but was not brought to her attention until 11/14/22 by the resident's (Resident #41) daughter. She completed a self reported document. She said, Initially when I saw the resident, I called the administrator. Then they went to the resident's bedside and the daughter showed them the pictures of the bruise on the resident's leg. She said that the nurse said that she forgot to put her note in. The DON said that they should have reported this incident in 2 hours. No changes with (Resident #15, the perpetrator) medications but she appeared more confused. Her norm was not going into other people rooms. She was not re-directable, so she grabbed onto Resident #41's right leg. She said they started the investigation on 11/14/22 and the DON said that she did see a bruise on the resident's leg. She also said that a note was put in Resident #15's chart of her going into Resident #41's room. She said that the outcome of the FRI was that the resident was sent to another facility that had a memory care unit and that Resident #15's daughter said that she was okay with the transfer. 2. For Resident #15, the perpetrator, the facility staff failed to report an abuse allegation involving the perpetrator within a two hour time frame. Resident #15 was admitted to the facility on [DATE]. Her admitting diagnosis includes Schizophrenia, Dementia and Bipolar Disorder. The quarterly revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/08/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #15 cognitive abilities for daily decision making were severely impaired. Resident #15 requires extensive assistance of one person with dressing, bed mobility, limited assistance of one person with locomotion on and off the unit, transfers, walking on the unit, walking in the corridor on the unit and personal hygiene, requires supervision set-up help only with eating, requires total dependence of one person with bathing. On 12/01/22 at approximately 1:00 PM an interview was conducted with the DON (Director Of Nursing) concerning the above incident. The DON said that the incident occurred on 11/12/22 at 4:07 AM. but was not brought to her attention until 11/14/22 by the resident's (Resident #41) daughter. She completed a self report document. She said, Initially when I saw the resident, I called the administrator. She said that the nurse said that she forgot to put her note in. The DON said that they should have reported this incident in 2 hours. 12/01/22 3:15 pm called family member concerning. Said she's ok with family member being in memory care at another facility. The Policy: Health Services will develop and implement policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, mistreatment, neglect, exploitation, and misappropriation of resident's property. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrence of resident abuse. Definitions: Abuse-Is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Abuse also concludes the deprivation by an individual. Including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Mistreatment means inappropriate treatment or exploitation of a resident. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Identification-Staff are encouraged to identify, correct and intervene in situations in which abuse, neglect is likely to occur. Protection: In the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and resident representative, and protect the resident from other residents from further harm or incident. On 12/01/22 receive inservice training record dated 11/15/22 at 8:30 AM. Subject: Changes to Reporting Resident Abuse After October 24, 2022 and How To Approach A Dementia Patient, Dated: 11/17/2022. No written statements from the staff were provided. On 12/01/22 at approximately 8:00 p.m., a pre-exit interview was conducted with the administrator, the DON, and the Corporate Consultant. The administrator said that the staff had received inservice training in July and on November the 15th (2022) and the staff didn't do what they were trained to do. At the conclusion of survey, no other documentation was presented. 3. The facility failed to timely report an allegation of neglect for one Resident (R) #99. Review of the facility's policy titled, Resident Abuse Policy and Procedure, dated 11/07/22 revealed, The facility Administrator/designee will report to the State survey and certification no later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse. During an interview with R99, on 11/30/22 at 9:12 AM, R99 stated that he had been dropped from the mechanical lift last summer. Review of R99's Face Sheet located in the electronic medical record (EMR) under the Resident Profile tab, revealed an admission date of 02/25/22 with medical diagnoses of Quadriplegia and Anxiety Disorder. Review of R99's quarterly Minimum Data Set (MDS) located in the EMR under the RAI tab with an assessment reference date (ARD) of 10 /21/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R99 was cognitively intact. The MDS revealed R99 required total assistance from staff for all activities of daily living (ADL). During an interview with the DON, the [NAME] President of Nursing (VPN), and the Assistant Director of Nursing (ADON) 5, on 11/30/22 at 4:27 PM, the VPN stated that nothing had been reported to the State survey and certification agency. Review of the self report document dated 11/30/22, revealed the event date was 06/10/22. The event type was noted to be an allegation of neglect. Description of event revealed the the resident claimed while being transferred with a lift he told the CNAs to stop because he felt he was slipping from the sling. The self report document indicated that according to [R99] they did not stop, and he slipped from the sling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, self report document, family and staff interviews, the facility staff failed to thoroughly investigate and take appropriate action as a result of investigation findings surrounding an abuse allegation involving two (2) residents. Resident #41 and Resident #15 (the perpetrator), a closed record resident and failed to thoroughly investigate an allegation of neglect for one (1) resident Resident #99, in a survey sample of 39 residents. The findings included: 1. For Resident #41 the facility staff failed to report and investigate a physical abuse allegation that resulted in the resident having a bruise on her right lower extremity to the Resident Representative, Administrator/ designee, APS (Adult Protective Services) or to the State survey and certification agency. The incident occurred on 11/12/22 but was not reported until 11/14/22. Resident #41 was admitted to the facility on [DATE] from an acute care facility with diagnosis Alzheimer's disease with late onset and Major Depressive Disorder. The annual, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/02/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long- and short-term memory problems as well as severely impaired for daily decision making. Resident #41 requires total dependence of one person with dressing, grooming, eating, toileting, and personal hygiene, requires and bathing. The care plan dated 11/29/17 indicated: Focus-Resident is totally dependent on staff for all ADLs (Activity of Daily Living). Goal-Resident will have personal hygiene needs met and be transferred safely without injury. Interventions: assist her to turn/reposition in bed frequently mech lift for transfers personal hygiene done by staff usually has 2-1/2 bedrails up. The initial self report document was not initiated until two days after the incident occurred with an event and report date of 11/14/22. The residents involved included Resident #41 and Resident #15 (a closed record resident). Resident #41 sustained a bruise as a result of the event. The self report document described an allegation of abuse/mistreatment dated 11/14/22 and indicated Resident #15 wandered into Resident #41's room and during attempts to re-direct Resident #15, she became combative and forcefully grabbed Resident #41's right leg causing a bruise. On 11/21/22 the final report of the event indicated a plan to address the wandering behaviors of Resident #15 included programming development for her cognitive impairments and to work toward finding placement to be near her son. Additional training in addressing combative behaviors, redirecting residents with these behaviors in a manner to avoid escalating agitation. Discussions during the Quality Assurance Committee Monthly meeting would address trends and patterns with corrective action plans implemented or revised if applicable. The fax confirmation dated 11/14/22 revealed the initial self reported documentation of the aforementioned event, sent to the State survey and certification agency which was 2 days after the event occured on 11/12/22. The fax confirmation dated 11/21/22 revealed the final self reported investigation documentation of the event sent to the State survey and certification agency. According to the abuse policy under Procedure: All alleged violations involving mistreatment, neglect, exploitation or abuse including injuries of an unknown source and misappropriation of residents property must be reported immediately to the administrator/designee of the facility. The facility Administrator or designee will then report by fax to VDH/OLC (Virginia Department of Health/Office of Licensure and Certification) no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in bodily injury. Resident to Resident altercations will be investigated as a potential abuse situation. An incident of willful intent that inflicts injury or harm to a resident by another resident is considered abuse and will be reported to the VDH/OLC and Adult Protective Services. A resident-to-resident suspected abuse will also be reported to law enforcement if appropriate. The facility must complete a thorough written investigation and must prevent further potential abuse while the investigation is in progress. A review of clinical records: 11/12/22 at 11:58 AM., indicated: Resident #41 had discoloration noted to the lower extremities. Long Term Care aware. Representative aware. The clinical notes dated 11/14/22 at 10:22 AM. Read: X-ray done as ordered, results show no fractures, no evidence of dislocation. no acute abnormality is seen. Results fax to provider. On 11/30/22 at approximately 12:11 PM., an interview was conducted with Resident #41s daughter at the resident's bedside concerning the incident. Resident #41 was observed resting quietly in her bed with her daughter and son at her bedside. The resident's daughter pulled back the blanket and sheet on the resident revealing a bluish discoloration about 1 inch in length on her right lower extremity below the resident's knee. She said that her mother's Right lower leg was still bruised on 11/14/22, two days after the incident occurred. She also said that due to her mom having thin skin she bruises easily. 2. For Resident #15, the perpetrator, the facility staff failed to report an abuse allegation involving the perpetrator within a two-hour time frame. Resident #15 was admitted to the facility on [DATE]. Her admitting diagnosis includes Schizophrenia, Dementia and Bipolar Disorder. The quarterly revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/08/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #15 cognitive abilities for daily decision making were severely impaired. Resident #15 requires extensive assistance of one person with dressing, bed mobility, limited assistance of one person with locomotion on and off the unit, transfers, walking on the unit, walking in the corridor on the unit and personal hygiene, requires supervision set-up help only with eating, requires total dependence of one person with bathing. A nursing note dated 11/22/22 at 11:44 AM., indicated Resident #15 was transferred to another facility. On 12/01/22 at approximately 1:00 PM an interview was conducted with the DON (Director Of Nursing) concerning the above incident. The DON said that the incident occurred on 11/12/22 at 4:07 AM. but was not brought to her attention until 11/14/22 by the resident's (Resident #41) daughter. She completed a self report document. She said, Initially when I saw the resident, I called the administrator. Then they went to the resident's bedside and the daughter showed them the pictures of the bruise on the resident's leg. She said that the nurse said that she forgot to put her note in. The DON said that they should have reported this incident in 2 hours. No changes with (Resident #15, the perpetrator) medications but she appeared more confused. Her norm was not going into other people rooms. She was not redirectable, so she grabbed onto Resident #41s right leg. She said they started the investigation on 11/14/22 and the DON said that she did see a bruise on the resident's leg. She also said that a note was put in Resident #15's chart of her going into Resident #41's room. She said that the outcome of the self reported investigation was that the resident was sent to another facility that had a memory care unit and that Resident #15's daughter said that she was okay with the transfer. The Policy: Health Services will develop and implement policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, mistreatment, neglect, exploitation, and misappropriation of resident's property. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrence of resident abuse. Investigate: During an investigation possible indicators such as bruises are abuse triggers and need further assessment. Resident #41 had bruises on her right lower extremity due to Residnet #15 pulling at her legs. On 12/01/22 received in-service training record dated 11/15/22 at 8:30 AM. Subject: Changes to Reporting Resident Abuse After October 24, 2022, and How to Approach A Dementia Patient, Dated: 11/17/2022. No written statements from the staff were provided at this time. On 12/01/22 at approximately 8:00 p.m., a pre-exit interview was conducted with the administrator, the DON, and the Corporate Consultant. The administrator said that the staff received prior abuse training. At the conclusion of survey, no other documentation was presented. 3. The facility failed to thoroughly investigate an allegation of neglect for one resident (Resident (R) 99. Review of the facility's policy titled, Resident Abuse Policy and Procedure, dated 11/07/22 revealed, The facility must complete a thorough written investigation and must prevent further potential abuse while the investigation is in progress. During an interview with R99, on 11/30/22 at 9:12 AM, R99 stated that he had been dropped from the mechanical lift last summer. He stated he had told Certified Nurse Aide (CNA) 2 to stop because it did not feel right while he was in the mechanical lift. R99 stated I said this isn't going to work. I wasn't secure to begin with. I told her to stop, and I jerked, and she just kept on. R99 stated CNA 2 did not stop and continued with the transfer. R99 stated, since the fall, something changed inside me. He stated he had more discomfort and pain since the fall. He stated it felt disrespectful that management had not talked with him about the fall until a week after the fall had occurred. Review of R99's Face Sheet located in the electronic medical record (EMR) under the Resident Profile tab, revealed an admission date of 02/25/22 with medical diagnoses of Quadriplegia and Anxiety Disorder. Review of R99's quarterly Minimum Data Set (MDS) located in the EMR under the RAI tab with an assessment reference date (ARD) of 10 /21/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R99 was cognitively intact. The MDS revealed R99 required total assistance from staff for all activities of daily living (ADL). Review of the Progress Note dated 06/10/22 found in the EMR under the Resident Profile, signed by the Nurse Practitioner revealed, I found [R99] to be laying on the floor under the Hoyer lift with his head of the bottom leg of the lift. He had the Hoyer sling partially underneath him. He was awake, alert and very shaken by the incident. Staff assisted him back to bed. He states that he hit the back of his head on the metal leg of the lift. He tells me that I tried to tell them that it was not hooked up right. He tells me that when he fell, he was in the sling at approximately the level of his bed. It is unclear exactly what happened. Review of the event report dated 06/10/22, revealed R99 fell on [DATE] at 12:30 PM and revealed R99 had Swelling left low back of head and mid low back of head. The incident report revealed R99 Slipped from pad. Review of the Statement Form dated 06/10/22, signed by CNA2, revealed At 12:30 PM I was helping [CNA 3] putting [R99] back to bed he slide [sic] out of the pad unto the lift he hitted [sic] the legs I called for nurses to looked [sic] at him. Review of the Statement Form dated 06/10/22, signed by CNA3, revealed I went in room around 12:30 [PM] to give [R99] a bath. [CNA2] came in and said [R99] wanted to go to bed. She help [sic] me put him to bed. We were connecting the Hoyer lift (Mechanical Lift) pad to the Hoyer lift and started lifting him when he first got lifted in the air, I heard the Hoyer lift snap like it was about to fall but the recliner chair was still behind him. [CNA2] was still lifting the Hoyer lift and she told me to lower the bed. In the middle of me lifting the bed [R99] said he feel [sic] like he falling [sic] next thing you know he fell and hit his head on the Hoyer lift. Review of the Statement Form dated 06/16/22, signed by the Corporate Infection Preventionist (CIP) revealed Resident interview after staff reporting [R99] wanted to speak to someone about concerns surrounding fall on 06/10/22 .[CNA2] did not listen to him when he told her it felt like the leg portion of the sling was not properly secured .He told [CNA2] please stop it feels like I'm slipping .[CNA2] was operating the lift controls. During an interview with the DON, the [NAME] President of Nursing (VPN), and the Assistant Director of Nursing (ADON) 5 on 11/30/22 at 4:27 PM, the DON stated that CNA 2 should have listened to the resident. The resident knows if there is a problem, The VPN confirmed that an abuse investigation had not been completed. During an interview with the Corporate Infection Preventionist (CIP) on 11/30/22 at 4:50 PM, she confirmed she had interviewed R99 on 06/16/22 (six days after the fall). She stated the reason she had interviewed him was because staff kept hearing from him. She stated this was the first time the resident had been interviewed. During an interview with the VPN on 11/30/22 at 6:48 PM, the VPN stated she would begin the investigation. During an interview with the Nurse Practitioner, on 12/01/22 at 4:39 PM, she stated, after R99 fell, she had seen the resident. She stated R99 told her, I tried to tell them that it was not hooked up right. The Nurse Practitioner stated that after R99 told her this, she had reported the information to staff. Review of the self report document dated 11/30/22, revealed the event date was 06/10/22. The event type was an Allegation of Neglect. Description of the event revealed that the resident claimed while being transferred with a lift he told the CNAs to stop because he felt he was slipping from the sling. According to [R99] they did not stop, and he slipped from the sling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation, the facility staff failed to ensure that 1 of 39 residents (Resident #51) in the survey sample received a complete and accurate assessment Minimum Data Set (MDS). The findings included: Resident #51 was originally admitted to the nursing facility on 03/25/19. Diagnosis for Resident #51 included but are not limited to anxiety and depression. The most recent (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 09/10/22 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 05 out of a possible score of 15, which indicated severe cognitive impairment for daily decision-making. Under section P (under restraints/alarms) was coded for the use of a wander/elopement alarm. A review of the quarterly assessment with an ARD date of 06/10/22 under section P (under restraints/alarms) was not coded for the use of a wander/elopement alarm. Resident #51's comprehensive care plan with a revision date of 09/02/22 identified Resident #51 at risk for wandering. Some of the interventions/approaches the staff would use to accomplish this goal is record behaviors on Behavior Tracking Form, redirect resident when wandering is observed and use wander guard/location monitor daily. During the review of Resident #51's Physician Order Summary (POS) for November 2022 revealed an order for a wander alert to alert staff if resident attempts to exit the facility without assistance. Check placement every shift by staff starting on 04/20/22. A review of Resident #51's Treatment Administration Record (TAR) was reviewed for the month of June 2022. The TAR revealed nurse's initials being signed off daily for the use of a wander guard device. On 12/01/22 at approximately 9:35 a.m., Resident #51 was observed sitting in his wheelchair. The wander guard bracelet was observed to his left ankle. An interview was conducted with MDS Coordinator #1 on 12/01/22 at approximately 10:10 a.m. She stated the MDS dated [DATE] was coded inaccurately and should have been coded for the use of a wander guard device. A debriefing was held with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations and [NAME] President of Nursing on 12/01/22 at approximately 8:00 p.m., who were informed of the above findings. No further information was provided prior to exit.

Based on resident interview, staff interviews and clinical record review, the facility staff failed to ensure 1 out of 39 residents (Resident #4) in the survey sample received the services needed to meet their dental needs. The findings included: The facility staff failed to follow-up with a dental visit recommended by the dentist on 07/31/22 for Resident #4. Diagnosis for Resident #4 included but not limited to Major Depressive Disorder. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 9/01/22 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15, which indicated no cognitive impairment for daily decision-making. The MDS coded Resident #4 supervision with oversight, encouragement or cueing with eating. Under section L0200 (Dental), nothing was coded for Resident #4. An interview was conducted with Resident #4 on 11/30/22 at approximately 11:10 a.m. She said that she had two bad teeth in the back of her mouth that needed to be pulled. She also said that a dentist came to visit 4 or 5 months ago saying that her teeth need to be pulled and she should have a follow-up appointment. My teeth have cracks in them and pieces of my teeth have broken off. She was asked if she was having trouble eating but said the broken teeth do not keep her from eating. The resident currently denied any pain or discomfort at this time. On 12/01/22 at approximately 5:00 PM., the DON (Director of Nursing) presented a dental note dated 9/14/22. In summary it read that resident had a cleaning. A concern from the resident was of #11, 14 and decay with #10, but no pain. The dental note also indicated that Resident #4 needed to have her teeth extracted (#11,#14) due to her teeth being broken and tooth #10 is decayed. On 12/01/22 at approximately 5:18 PM., an interview was conducted with the SW (Social Worker/OSM/Other Staff Member #6) concerning the above issue. She said that the nursing staff or the ADON (Assistant Director of Nursing) was responsible for making the dental appointment. On 12/01/22 at approximately 6:10 PM., a phone call was made to the ADON (Administrative Staff #5) concerning the above. A voice message was left. On 12/01/22 at approximately 6:15 PM., a phone call was made to the ADON (ASM/Administrative Staff Member #6) concerning the above. She said that there are two ADON's, but ASM #5 (Administrative staff #5) was responsible for making the dental referral for Resident #4. On 12/01/22 at approximately 8:00 p.m., a pre-exit interview was conducted with the administrator, the DON and the Corporate Consultant. The DON said that the Nurse Practitioner should have been informed of the residents dental findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and review of facility documents, the facility's staff failed to have an appropriate call bell accessible and functional for a resident with bilateral contractured hands for 1 of 39 residents (Resident #226) in the survey sample. Resident #226 was originally admitted to the facility on [DATE] from the community. The current diagnoses included; Quadriplegia and Contracture Right and Left Hands. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/29/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long- and short-term memory problems as well as severely impaired for daily decision making. In section G(Physical functioning) the resident was coded as total dependence of one person for bathing, dressing, eating, toilet-use, personal hygiene and bathing. Functional Status G0400: Functional Limitation In Range of Motion: Resident coded as having impairment on both sides for upper extremities. Problem: The care plan dated 11/22/22 read that Resident #226 has the potential for health and safety concerns. Effective 11/22/22. Goal: Maintain Resident's safety through appropriate assistance and safety measures. Effective 11/22/22. Interventions: Provide communication device. Effective 11/22/22. An addendum to Resident #226 care plan reads: Standard call bell replaced with pancake style due to contractures in both hands. Effective 11/30/22. During the initial tour on 11/29/22 at approximately 2:57 PM., Resident #226 was observed laying on her back in bed with both hands contractured. The call bell was located near her right upper arm. She was asked how was she doing and stated, My head hurts and that sucks. She was then asked if she could use her call bell to ask for assistance. She stated, No. On 11/29/22 at approximately 3:10 PM LPN (Licensed Practical Nurse) #11 was informed that the resident needed assistance and couldn't use her call bell. LPN #11 said that they have the flat call bells that can be placed on the resident's chest. She also said that she would have to see if maintenance has one. On 11/30/22 at approximately 11:30 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #7 concerning the resident's call bell (Standard Style). She said that the resident has only been here since last week (11/22/22). She will look into it. On 11/30/22 at approximately 1:17 PM., an observation was made of Resident #226 resting in bed with a pancake style call bell at her bedside. On 12/01/22 at approximately 6:30 PM., an interview was conducted with LPN #11 concerning the Residents' call bell. She said that she and the DON (Director Of Nursing) plugged in the pancake call bell a few days ago. She was asked if Resident #226 was able to use the pancake device. She said that she was not sure if resident could use it. A review of nursing notes dated 11/30/2022 at 7:46 PM., read: Staff reported to DON that resident assess for use of call bell by nurse, resident unable to use the current call bell system due to bilateral contractures in both hands pancake call bell system was placed resident will continue to be monitored. On 12/01/22 at approximately 8:00 PM., a pre-exit interview was conducted with the administrator, the DON and the Corporate Consultant. The DON said that when the resident arrived to the unit the staff should have assessed her ability to use the call bell.

Based on deficiencies determined during this survey the QAA (Quality Assessment and Assurance) and Quality Assurance and Performance Improvement (QAPI) committee failed to develop and implement corrective plans of action and monitoring to ensure the necessary systems were in place and correct identified quality deficiencies related to a fall on 6/10/22 for one resident (Resident #99) out of a survey sample of 39. The findings included: On 12/01/22 at approximately 4:38 p.m., an interview was conducted with the Administrator, Director of Nursing, [NAME] President (VP) of Operations, [NAME] President (VP) of Nursing and on the phone was the [NAME] President of Quality. The VP of Nursing stated the Quality Assurance Plan is used to ensure systems are evaluated, any quality care concerns are addressed and tracked for improvement. The VP of Operations stated Resident #99 fell out of the Hoyer lift during a transfer on 06/10/22. She stated she did not realize the investigation wasn't completed until information related to the fall was requested by Surveyor #1. She said almost everything related to the investigation on Resident #99's fall on 06/10/22 is missing except for a couple pieces of documentation. She stated only eight (8) staff members were educated on how to properly use a Hoyer lift. The VP of Nursing stated the fall was taken to QAPI; however, those who were designated to complete their part of the QAPI plan did not finish the observation, training or completing the fall investigation. The VP of Nursing stated QA should have assigned the task to a specific person and given a direct timeframe when the fall investigation should have been completed. The VP of Nursing stated there was a breakdown in the QA process related to Resident #99's on 06/10/22. The QAA committee is responsible for identify and correcting identified quality deficiencies. The facility was not able to provide evidence that the facilities QAA meeting had a systematic plan in place to maintain and improve the safety and quality in the facility involving the resident and staff and took the necessary steps to identify the cause and correct the problem. A debriefing was held with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations and [NAME] President of Nursing on 12/01/22 at approximately 8:00 p.m., who were informed of the above findings. No further information was provided prior to exit. The facility's policy titled QAPI Plan - Effective 11/17/22. Addressing Care and Services: The QAPI program will aim for safety and high quality with all clinical interventions and service delivery while emphasizing autonomy, choice, and quality of daily life for residents and family by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis, and corrective action. The scope of the QAPI program encompasses all types and segments of care and services that impact clinical care, quality of life, resident choice, and care transitions. These include, but are not limited to, care management and patient safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interview the facility staff failed to maintain an effective pest control program. The findings included: Resident #35 stated during an interview on 11/29/22 at 2:35 PM that she did not like taking showers in the women's shower room on the Huntington Unit because it had drain flies. Observations made on 11/29/22 at 2:45 PM indicated drain flies were noted in the women's shower room. On 11/30/22 at 9:20 AM two live roaches were observed on the Huntington Unit near room [ROOM NUMBER]. During kitchen observations on 11/29/22 at 11:30 AM, 11/30/22 at 11:48 AM and 12/1/22 at 12: 48 PM, drain flies and gnats were observed in the kitchen. During an interview on 12/1/22 at 1:30 PM the Director of Dining and Nutrition stated that pests were on the list of corrections for the kitchen area. During an interview on 12/1/22 at 4:45 PM the Administrator stated that the pest control company comes out every other week to spray and as needed if called.

Based on a complaint investigation, resident and staff interviews, the facility staff failed to ensure sufficient staff were available to carry out the functions of the food and nutrition services. The findings included: The facility failed to have sufficient staff on 04/17/22 to carry out the functions of the food and nutrition services. During an interview on 11/30/22 at 1:37 PM Resident #82 voiced concern about food. Resident voiced concerns about the facility not having enough staff to serve and prepare food. Resident #82 stated the facility served the residents a granola bar, a carton of juice and a cup of fruit for breakfast a few months ago because the facility did not have enough staff. During an interview on 12/01/22 at 9:58 AM Dietary Aide #1 stated on the morning of April 17, 2022 which was Easter Sunday, she was the only dietary staff on duty. Dietary Aide #1 stated she did the best she could to provide a breakfast meal to the residents. The meal consisted of granola bar, a carton of juice and a cup of fruit for those residents on a regular diet. For residents on a puree, mechanical soft or chopped diet, they were given a cup of apple sauce and a carton of milk. The census of the facility was 134 on this date. Dietary Aide #1 was asked if this has happened before and she stated, yes. I tried to do all that I could for the residents. Dietary Aide #1 was asked if she had called and informed the administrator or Dietary Manager of the staffing issues and she stated, yes. During an interview on 12/1/22 at 9:48 AM the Director of Dining and Nutrition stated, we have been down with the kitchen staff for months. Some days we only had three staff for the entire day. At times we have asked the Certified Nursing Assistants (CNA'S) to help with dish washing. The required staffing is between 11-12 staff. We have been running the kitchen with only three staff. I have developed a Root Cause Analysis & Action Plan. The Director of Dining and Nutrition was asked if she was aware of the Easter Sunday staffing problems and she stated that she was informed the next day. A revised Dining Service, Food Service and Meal Distribution Policy dated 10/11/22 indicated: Policy-Dining services will meet the individual nutritional needs of each resident. Menus are planned to provide each resident with a resident specific, nourishing, palatable, and well-balanced diet. Service and distribution will be conducted in a manner that meets federal, state and local guidelines. Dining Service Staff: Sufficient, competent dining services staff are employed to carry out the functions of the dinning services department. Complaint Deficiency

Based on resident and staff interviews, the facility staff failed to ensure menus were followed as pre-planned. The findings included: The facility staff failed to ensure menus were followed as planned on 4/17/22 due to having insufficient staff. During an interview on 11/30/22 at 01:37 PM Resident #82 voiced concern about food. Resident voiced concerns about the facility not having enough staff to serve and prepare food. Resident #82 stated the facility served the residents a granola bar, a carton of juice and a cup of fruit for breakfast a few months ago because the facility did not have enough staff. A review of the facility menu dated 4/17/22 for breakfast indicated: Juice/cranberry PC, Cereal Chex [NAME] PC, Muffin Blueberry RTS, sausage link, 2 each, milk 2% 8 ounces, and 8 ounces of coffee. During an interview on 12/01/22 at 9:58 AM Dietary Aide #1 stated on the morning of April 17, 2022 which was Easter Sunday, she was the only dietary staff on duty. Dietary Aide #1 stated she did the best she could to provide a breakfast meal to the residents. The meal consisted of granola bar, a carton of juice and a cup of fruit for those residents on a regular diet. For residents on a puree, mechanical soft or chopped diet, they were given a cup of apple sauce and a carton of milk. Dietary Aide #1 was asked if the facility had an emergency back up breakfast menu and she stated, no, not at that time. During the Group Meeting conducted 11/29/22 at 3:30 PM, the residents stated the shrimp that was on the lunch menu for the day was burnt, hard and over cooked. The french fries were cold and not edible and the menu did not match what was served. During an interview on 12/1/22 at 9:48 AM the Director of Dining and Nutrition stated, there were no emergency menus in place until she developed them in May of 2022. A Dining Service, Food Service and Meal Distribution Policy and Procedure dated 10/11/22 indicated: Policy: Menus are planned to provide each resident with a resident specific, nourishing, palatable, and well-balanced diet. Service and distribution will be conducted in a manner that meets federal, state and local guidelines.

Based on observations, resident and facility staff interview, the facility staff failed to prepare food that conserves nutritive value, flavor and appearance. The findings included: During an interview on 11/30/22 at 9:16 AM Resident #82 voiced concern about his food. Resident #82's concern was how his breakfast food was prepared and presented. Resident #82's breakfast tray was observed to included scrambled eggs, french toast and two sausage patties. The scrambled eggs were observed to be runny and juicy. The sausage patties were observed to be blacken in color. Resident #82 stated the sausage patties were to hard to eat. The French toast sticks were observed to be about 1/4 thick and unrecognizable. During an observation and interview with Resident #99 on 11/30/22 at 9:12 AM, Resident #99 received his breakfast tray with large portion of unseasoned scrambled eggs, one patty of sausage which was black in color and approximately three French toast sticks, one was approximately 1/8 inch thick and unrecognizable. Resident #99's family member was feeding the resident. She stated she was not sure what the sausage patty was and both stated, it is not edible. A Group Meeting attended by five residents was conducted 11/29/22 at 3:30 PM, the residents stated the shrimp that was on the lunch menu for the day was burnt, hard and over cooked. She said the french fries were cold and not edible and the menu did not match what was served. During observations of the kitchen on 11/30/22 at 11:48 AM, white rice that was prepared for lunch appeared dry and was noted with a dark brown crust on the outer edges. Gravy that was prepared for lunch appeared lumpy and congealed. During an interview on 11/30/22 at 11:52 AM the main cook stated, the rice was a bit over cooked and the gravy needed some water to thin out the lumps. A Dining Service, Food Service, and Meal Distribution Policy dated 10/11/22 indicated: Dining services will meet the individual nutritional needs of each resident. Menus are planned to provide each resident with a resident specific, nourishing, palatable, and well-balanced diet. Service and distribution will be conducted in a manner that meets federal, state and local guidelines.

Based on observations and staff interview, the facility staff failed to store and serve food under sanitary conditions. The findings included: During the kitchen observations on 11/29/22 at 11:27 a.m., the left wall next to the four burner stove and two door oven, was noted to have copious amounts of burnt grease and food particles. Behind the stove was burned food particles and food crumbs. Food and debris was observed behind the standing two part oven. The wall next to the eight burner stove was observed to have a hole that measured an estimated 10 inches long and 3 inches wide. Rust and corrosion was noted on the electrical sockets next to the deep fryer. The wall behind the three compartment sink was observed to have food and debris. The drain hole under the prep severing table was observed to have black like matter. The wall behind the ice machine was observed to have an estimated 8 inch by 3 inch hole. The plaster was observed to be coming off. Trash and debris was observed behind the ice machine. The kitchen floor was noted to have a brown film on it. In the dish wash room food and debris were observed on the floor. In the walk in refrigerator food and trash were observed on the floors. In the walk in freezer, food and trash was observed on the floor. A heavy build up of ice was observed coming from the sprinkle nozzle in the freezer. The dry storage room was observed with trash, food and debris. Rusted racks over the three compartment sink used to store clean, drying food storage containers were observed. A November 17, 2021 Local health department citation indicated the same uncorrected observation. The wall leading into the dinning room was observed to have a hole measuring approximately 6 inches by 4 inches. The wall was observed to have rotten wood and crumbling plaster. During an interview on 12/01/22 at 9: 48 AM the Director of Dining and Nutrition stated, we have been working on these issues for a few months. We have been trying to get things repaired. A Cleaning and Organization Task List dated 9/22/22 indicated: Need to implement significant plan for improvement. Kitchen shut down for 2-3 days for cleaning and organization. Repairs to base and floor. Organization of walk in freezer. Power wash floors in walk-in Power wash floors in prep area Power wash all carts-utility and serving Removing all pans to deep clean shelving Remove all items under tray line for deep clean Clean toaster Deep clean stove and oven Deep clean/power wash under three compartment sink Clean all vents Clean and replace any missing lights Repair missing titles Deep clean walls. A Dining Service, Food, Service and meal Distribution Policy Indicated: Service and distribution will be conducted in a manner that meets federal, state and local guidelines. Food Service- Food is stored, prepared, distributed and served to residents under sanitary conditions in accordance with professional standards. Repairs: Any repairs needed in the dietary department are to be reported promptly to the dinning service manager or supervisor and or administrator/designee. Effective procedures are established for the cleaning and sanitizing of all equipment and work areas.

Based on observations, and staff interview the facility staff failed to ensure garbage and refuse was disposed properly. The findings included: On 12/01/22 at 2:10 PM two of three outside garbage and refuse containers were observed with open container doors. The area around the refuse containers were observed with trash and debris. Two chairs and a sofa was observed in the area around the dumpster. A dresser drawer was observed in the area along with a pile of old wooden fencing. The area outside the kitchen door was observed to have pools of standing water, leaves, trash and debris. The administrator who accompanied the surveyor during the observations stated, the areas will be cleaned up immediately and the outside service for the dumpers will be called to replace the dumpster due to the doors not closing properly.

Based on observations, interviews, document review, policy review and review of Centers for Medicare &Medicaid Services (CMS) Quality, Safety & Oversight (QSO) memo, the facility failed to ensure that contact tracing of residents and staff was conducted, after identifying Licensed Practical Nurse (LPN)7 tested positive for Coronavirus Disease (COVID-19). This deficient has the potential to affect all of the residents in the facility. Findings Include: Review of the CMS QSO-20-38-NH [Nursing Home] revised 09/23/22 revealed, an outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed . Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g., facility-wide) testing . If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. Review of the facility's policy titled COVID-19 Testing and Results dated 11/04/22, revealed, Outbreak is defined as a new SARS-CoV-2 infection in any healthcare personnel (HCP) or any nursing home-onset SARS-CoV-2 infection in a resident. An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed. An outbreak investigation would not be triggered when a resident with known COVID-19 is admitted directly into transmission-based precautions (TBP), or when a resident known to have close contact with someone with COVID-19 is admitted directly into TBP and develops COVID-19 before TBP are discontinued. Otherwise, a new SARS-Cov-2 infection would be considered nursing-home onset. Review of facility policy titled COVID-19 Testing and Results dated11/04/22 revealed, Outbreak testing: An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed. If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on contact tracing Contact Tracing Approach: Immediately (but not earlier than 24 hours after the exposure, if known) test staff that had a high-risk exposure and all residents that had close contact with a COVID-19 positive individual. If negative, test again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day I (where day of exposure is day 0), day 3, and day 5 . If positives are identified, conduct additional contact tracing and testing and consider a change to the broad-based approach .Employee tests positive .Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations in the nursing home will be altered. Initiate contact tracing to identify staff that had higher-risk exposure to and others that had close contact with the staff member while they were contagious. During an observation conducted on 11/29/22 11:15AM, revealed an education signation on door which indicated that the community rating was high and the last COVID-19 in the building was in October 2021. During an interview conducted on 11/29/22 12:00 PM, the Director of Nursing (DON) stated that there was one COVID-19 positive resident that was admitted from hospital with COVID-19 and that there was one COVID-19 positive employee, LPN7, as of 11/25/22. Review of the facility's testing sheet identified LPN7 tested positive for COVID-19. Review of the facility's Outbreak investigation document revealed that LPN7 had only a two-minute interaction with a resident and was wearing Personal Protective Equipment (PPE). The document indicated that resident was not tested due to it not being necessary according to the facility policy. During an interview conducted on 11/29/22 02:45 PM, Register Nurse (RN1), [NAME] President of Nursing (VPN) and DON were asked why the facility did not have signage posted indicating the facility was in outbreak status. The VPN stated that they were not in outbreak status. When asked about CMS QSO memo that one resident or one employee puts the facility in outbreak status. The VPN stated that she read another memo that stated that they were not in outbreak status and that she believed that having more than one person counts as being in outbreak status. At this time, the VPN did not show the surveyors the memo nor indicate who the memo was from. When asked why contact tracing was not conducted after LPN 7 tested positive for COVID-19. DON stated that she did not do contact testing because LPN7 did not come within six feet of the resident and was not there for more than two minutes. When asked about when LPN 7 conducted at shift change and the count of controlled medication in the medication cart, LPN7 was in close contact with the outgoing LPN6. The VPN stated that the facility did not believe they were in outbreak status. VPN and DON admitted that they did the outbreak investigation and testing page and created the documents dated11/28/22. During an interview with Infection Preventionist (IP) on 11/30/22 08:15AM when asked about LPN7 testing positive for COVID-19 and whether outbreak testing was conducted, the IP stated that she informed administration that they were in outbreak status and that signage needs to go up and that contact tracing and testing needed to be performed. She was informed by the VPN that the facility was not in outbreak status. The IP was told that one employee did not qualify as an outbreak. During an interview with VPN, RN1 and DON on 11/29/22 01:47 PM. VPN stated, employee came in and was tested at the facility and was positive for COVID-19 on 11/25/22. VPN, RN1, DON stated that they received a memo from CMS that one person does not qualify as an outbreak status. The VPN could not find the CMS memo that stated that they were not in outbreak status. During an interview and review of documents on 11/30/22 at 01:38 PM, when asked if they knew for sure that LPN7 did not come into close contact with the resident, VPN and DON could not say LPN7 did not in fact come within 6 ft of the resident. During an interview on 11/30/22 01:34PM, the IP stated that it is an expectation that the facility would have tested the resident that was in contact with LPN7, and that the facility would then be on outbreak status. During an interview on 12/01/22 03:57 PM, LPN 7 stated that she and LPN 6 were in close contact with each other for more than 15 minutes. LPN7 stated that she went to the resident's room and asked her if she already received her as needed pain medication. The resident stated that she had received the pain medication and LPN7 then left the room.

Based on clinical record review, staff interview and facility documentation the facility staff failed to assure that 1 of 46 residents (Resident #84) in the survey sample received a complete and accurate assessment. The facility staff failed to ensure the MDS with an Assessment Reference Date (ARD) of 03/08/19 under Section N (Medications) for the use of an antipsychotic medication (Seroquel) was coded correctly for Resident #84. The findings included: Resident #84 was admitted to the facility 3/01/19. Diagnosis for Resident #84 included but not limited to *Vascular Dementia with behavior disturbances. Resident #84's quarterly MDS with an Assessment Reference Date (ARD) of 03/08/19 coded resident with a BIMS score of 02 out of a possible 15 indicating severe cognitive impairment. Review of Resident #84's quarterly MDS with an ARD of 03/08/19 was coded one (1) for receiving Antipsychotic medications. Section N on the MDS under medications received read as follows: Indicate the number of DAYS the resident receiving the medication during the last 7 days, enter 0 if medication was not received by the resident during the last 7 days. Resident #84's comprehensive care plan documented resident at risk for side effects related to use of psychoactive medications. Some of the goals set for the resident included not but not limited to: will achieve desired effect from ordered medications, and will have no negative effects from medication use as ordered. Some of the intervention to manage the resident's goal include observing and reporting signs/symptoms of tardive dyskinesia, complete AIMS per facility policy, consult, and coordinate care with mental health professional per physician order. The physician order reads: Starting on 03/01/19-*Seroquel 25 mg tablet-give 1 tablet by mouth at bedtime for five days (psychotic disorder with delusions). Review of Resident #84's March 2019 Medication Administration Record (MAR) revealed the medication Seroquel was administered three times for the look back period of 7 days for the MDS with an ARD date of 03/08/19. An interview was conducted with MDS Coordinator on 4/18/19 at approximately 5:22 p.m. She compared the March 2019, MAR with the MDS with an ARD date of 03/08/19 under section N, and then stated, The MDS should have been coded (3) for the amount of times administered. The surveyor asked, Is this an accurate MDS she replied, No, not for this assessment. The facility administration was informed of the finding during a briefing on 04/18/19 at approximately 5:25 p.m. The facility did not present any further information about the findings. CMS's RAI Version 3.0 Manual (Chapter 1: Resident assessment Instrument (RAI) 1). 1.3 Completion of the RAI (1) the assessment accurately reflects the resident's status. Goals: The goal of the MDS 3.0 revision are to introduce advances in assessment measures, increase the clinical relevance of items, improve the accuracy and validity of the tool, increase the resident's voice by introducing more resident interview items. Providers, consumers, and other technical experts in the nursing home care requested that MDS 3.0 revision focus on improving the tool's clinical utility, clarity, and accuracy. Definitions: *Seroquel tablets and extended-release tablets are also used alone or with other medications to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods) ( (https://medlineplus.gov/ency/article/007365.htm). *Vascular dementia is a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain (https://www.mayoclinic.org/diseases-conditions/vascular-dementia/symptoms).

Based on observations, clinical record review, staff and resident interview and facility document review, the facility staff failed to ensure a person-centered baseline care plan was developed within 48 hours of admission that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 46 residents (Resident #440) in the survey sample. Resident #440, a newly admitted stroke resident, had difficulty at times communicating her needs to the nursing staff (expressive aphasia). The facility staff failed to ensure communication needs were included in the 48 hour baseline care plan. This failure resulted in resident frustration during episodes of her inability to communicate verbally or through gestures. The findings included: Resident #440 was admitted to the nursing facility on 4/12/19 with a diagnosis of atrial fibrillation and history of cerebral infarction (stroke) with left sided hemiplegia. The resident's Minimum Data Set (MDS) assessment was not due. The 48 hour baseline care plan dated 4/12/19-4/14/19 identified the resident had the potential for impaired quality of life related to a new environment and change in health status. The goal set by the staff for the resident indicated that the resident would not experience adverse effects for new admission or new environment. There were no approaches that addressed the resident's difficulty in communication in order to create and maintain a safe environment and psychological well-being. The care plan did not identify the stroke and any deficits she had as a result of past or current stroke with staff interventions and/or resident needs. The following observation was made of Resident #440 on 4/17/19 at 12:10 p.m.: Resident #440 was positioned in the doorway of her room in her wheelchair. She summoned the Certified Nursing Assistant (CNA) #1 and asked her what sounded like a couple of pictures. When the CNA could not understand her after several attempts, a second and third staff approached the resident due to the resident's obvious distress. These persons were not able to understand the resident as she kept repeating the same phrase over and over a couple of pictures. The Unit Manager, Licensed Practical Nurse (LPN) #3 asked the resident several times to tell her what she wanted and the same phrase was repeated by the resident. The resident began stomping her feet, shaking her head from sided to side, hitting herself violently and screaming as loud as she could as she cried with tears streaming down her face. Three more times the CNA, Unit Manager and others surrounded the resident asking her what she wanted to no avail. CNA #1 pulled the resident into her room as the resident continued the same aforementioned behavior. The resident pointed to this surveyor with her right hand and motioned to come to her. Once the resident was approached she appeared to want what this surveyor was holding, a clip board, but no one was sure why. This surveyor asked the group, Does she use a communication board? The Unit Manager ran to the nurse's station and returned approximately 5 minutes later with a communication sheet and pointed to several pictured items and letters, but the resident continued with her frustrated behavior. The resident motioned again to this surveyor. The question was asked at this point, Does she write? One of the staff present retrieved a blank sheet of paper, gave it to her with a pen as the resident tried to write in cursive with the paper on her left thigh. No one could read the message the resident tried to write. Due to the resident's continued behaviors of screaming, crying, stomping and slapping herself, this surveyor came closer to the resident. The resident took the clipboard placed the paper on the clipboard and was prompted to print what she was trying to tell the staff. The resident printed very clearly, cowboy picture pointing to the television. CNA #1 immediately said, She wants the television channel to remain on the channel that has cowboys on it. As quickly as the extreme outburst began, it ended and the resident rose her right hand to high five everyone with smiles. CNA #1 said, Oh that's right, her daughter wrote it on a piece of paper and told us to keep the channel on 75 which is a cowboy channel. On 4/18/19 at 10:30 a.m., an interview was conducted with the speech therapist (ST). She stated the resident was screened and assessed on 4/15/19 with a new stroke, but had a history of previous stroke with some expressive aphasia per information from the resident's daughter. The ST stated she thought the most recent stroke resulted in left sided weakness. The ST evaluation dated 4/15/19 indicated the resident had severe impairment in articulation with moderate intelligibility, but the fluency was within normal limits meaning that she could put several words together. When the episode from 4/17/19 at 12:10 p.m. was explained to the ST, she stated the goal was to increase articulation, but when all else fails and the resident becomes frustrated, a pen and pad of paper was necessary in order to reduce frustration and have her needs met, as well as a communication board. When asked where this information was written because it was not in the ST screening evaluation, or how the information was relayed to the nursing staff she said, That is not what I do, the rehabilitation director would share that information with the nursing staff. On 4/18/19 at 12:15 p.m., the rehabilitation director stated the ST should have shared what the resident needed to communicate with the nursing staff in order to have her needs met. She also said during the morning meetings especially on the skilled unit where the resident resided results of screenings and evaluations are shared with nurse managers and the MDS nurse, along with reading the therapy notes, thus the care plan would reveal the need with goals and interventions. The ST stated it was her expectation that once the evaluation is completed, the charge nurse, therapy head and Director of Nursing (DON) be made aware of what is needed for patients care; in this case a communication board, paper and pen if able to write to avoid times of frustration when the resident cannot verbally communicate her needs. She stated once everything is completed, nursing will update the care plan. She presented a re-evaluation 4/18/19 at 3:15 p.m. that was conducted shortly after this interview that educated the resident on strategies on how to slow her speech rate, increase intensity and over exaggerate sounds to increase speech intelligibility. The evaluation included provision of communication board, pad and pen to increase communication wants and needs and that this was an alternative means to communication in case of communication breakdown. On 4/18/19 at approximately 5:00 p.m., an interview was conducted with the Administrator, the DON and the Assistant Director of Nursing Operations (ADNO). The DON stated even without any information from ST, he expected the nursing staff to have been able to handle the aforementioned situation and provide the resident with either a communication tool or pad and pencil. The Administrator stated, I think that situation could have definitely been handled better for the resident's sake as well as safety. During the debriefing with the Administrator, DON and ADNO on 4/18/19 at approximately 6:00 p.m., no further information was provided prior to survey exit. The policy and procedures titled Person-centered Baseline and Comprehensive Care Plan dated 5/17/18 indicated all residents should have a person-centered baseline care plan developed within 48 hours of admission by the interdisciplinary team. The baseline care plan must address medical, nursing, mental, and psychosocial needs to include personal and cultural preferences. The baseline care plan must include, but is not limited to initial goals based on admission, physician orders, dietary orders, therapy services, social services, PASRR recommendations if appropriate.

Based on observations, clinical record review, staff and resident interview and facility document review, the facility staff failed to ensure the necessary person-centered care and services were provided for 1 of 46 residents (Resident #440) in the survey sample. Resident #440, a newly admitted stroke resident, had difficulty at times communicating her needs to the nursing staff (expressive aphasia). The facility staff failed to have the appropriate communication devices as needed when the resident was unable to verbally find the right words or gesture to enable the staff to understand her, which caused her extreme distress and frustration. The findings included: Resident #440 was admitted to the nursing facility on 4/12/19 with a diagnosis of atrial fibrillation and history of cerebral infarction (stroke) with left sided hemiplegia. The resident's Minimum Data Set (MDS) assessment was not due. The 48 hour baseline care plan dated 4/12/19-4/14/19 identified the resident had the potential for impaired quality of life related to a new environment and change in health status. The goal set by the staff for the resident indicated that the resident would not experience adverse effects for new admission or new environment. There were no approaches that addressed the resident's difficulty in communication in order to create and maintain a safe environment and psychological well-being. The care plan did not identify the stroke and any deficits she had as a result of past or current stroke with staff interventions and/or resident needs. The following observation was made of Resident #440 on 4/17/19 at 12:10 p.m.: Resident #440 was positioned in the doorway of her room in her wheelchair. She summoned the Certified Nursing Assistant (CNA) #1 and asked her what sounded like a couple of pictures. When the CNA could not understand her after several attempts, a second and third staff approached the resident due to the residents obvious distress. These persons were not able to understand the resident as she kept repeating the same phrase over and over a couple of pictures. The Unit Manager, Licensed Practical Nurse (LPN) #3 asked the resident several times to tell her what she wanted and the same phrase was repeated by the resident. The resident began stomping her feet, shaking her head from sided to side, hitting herself violently and screaming as loud as she could as she cried with tears streaming down her face. Three more times the CNA, Unit Manager and others surrounded the resident asking her what she wanted to no avail. CNA #1 pulled the resident into her room as the resident continued the same aforementioned behavior. The resident pointed to this surveyor with her right hand and motioned to come to her. Once the resident was approached she appeared to want what this surveyor was holding, a clip board, but no one was sure why. This surveyor asked the group, Does she use a communication board? The Unit Manager ran to the nurse's station and returned approximately 5 minutes later with a communication sheet and pointed to several pictured items and letters, but the resident continued with her frustrated behavior. The resident motioned again to this surveyor. The question was asked at this point, Does she write? One of the staff present retrieved a blank sheet of paper, gave it to her with a pen as the resident tried to write in cursive with the paper on her left thigh. No one could read the message the resident tried to write. Due to the resident's continued behaviors of screaming, crying, stomping and slapping herself, this surveyor came closer to the resident. The resident took the clipboard placed the paper on the clipboard and was prompted to print what she was trying to tell the staff. The resident printed very clearly, cowboy picture pointing to the television. CNA #1 immediately said, She wants the television channel to remain on the channel that has cowboys on it. As quickly as the extreme outburst began, it ended and the resident rose her right hand to high five everyone with smiles. CNA #1 said, Oh that's right, her daughter wrote it on a piece of paper and told us to keep the channel on 75 which is a cowboy channel. On 4/18/19 at 10:30 a.m., an interview was conducted with the speech therapist (ST). She stated the resident was screened and assessed on 4/15/19 with a new stroke, but had a history of previous stroke with some expressive aphasia per information from the resident's daughter. The ST stated she thought the most recent stroke resulted in left sided weakness. The ST evaluation dated 4/15/19 indicated the resident had severe impairment in articulation with moderate intelligibility, but the fluency was within normal limits meaning that she could put several words together. When the episode from 4/17/19 at 12:10 p.m. was explained to the ST, she stated the goal was to increase articulation, but when all else fails and the resident becomes frustrated, a pen and pad of paper was necessary in order to reduce frustration and have her needs met, as well as a communication board. When asked where this information was written because it was not in the ST screening evaluation, or how the information was relayed to the nursing staff she said, That is not what I do, the rehabilitation director would share that information with the nursing staff. On 4/18/19 at 12:15 p.m., the rehabilitation director stated the ST should have shared what the resident needed to communicate with the nursing staff in order to have her needs met. She also said during the morning meetings especially on the skilled unit where the resident resided results of screenings and evaluations are shared with nurse managers and the MDS nurse, along with reading the therapy notes, thus the care plan would reveal the need with goals and interventions. The ST stated it was her expectation that once the evaluation is completed, the charge nurse, therapy head and Director of Nursing (DON) be made aware of what is needed for patients care; in this case a communication board, paper and pen if able to write to avoid times of frustration when the resident cannot verbally communicate her needs. She stated once everything is completed, nursing will update the care plan. She presented a re-evaluation 4/18/19 at 3:15 p.m. that was conducted shortly after this interview that educated the resident on strategies on how to slow her speech rate, increase intensity and over exaggerate sounds to increase speech intelligibility. The evaluation included provision of communication board, pad and pen to increase communication wants and needs and that this was an alternative means to communication in case of communication breakdown. On 4/18/19 at approximately 5:00 p.m., an interview was conducted with the Administrator, the DON and the Assistant Director of Nursing Operations (ADNO). The DON stated even without any information from ST, he expected the nursing staff to have been able to handle the aforementioned situation and provide the resident with either a communication tool or pad and pencil. The Administrator stated, I think that situation could have definitely been handled better for the resident's sake as well as safety. During the debriefing with the Administrator, DON and ADNO on 4/18/19 at approximately 6:00 p.m., no further information was provided prior to survey exit. The policy and procedures titled Providing Auxiliary Aids for Persons with Disabilities dated 1/30/13 indicated the necessary provisions to ensure effective communication. Residents would be evaluated to identify is there would be a benefit from auxiliary aides and services. Facility staff would assist those residents with speech impairments in obtaining the necessary services to ensure they are able to achieve effective communication. These services may include, but are not limited to: computer, typewriter, flashcards, alphabet boards, communication boards, telecommunication devices, notepad, etc.

Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure a PRN (as needed) psychotropic medication (Ativan) order was limited to 14 days and failed to re-evaluate the resident for appropriateness of the medication for one resident (Resident #84) of 46 residents in the survey sample who was receiving a PRN (as needed) psychotropic medication. The facility staff failed to ensure a PRN (as needed) psychotropic medication (Ativan) order was limited to 14 days. The physician did not do an evaluation of Resident #84 to extend the psychotropic medication passed 14 days and did not document the rational and duration in the resident's medical record. The findings included: Resident #84 was admitted to the facility 3/01/19. Diagnosis for Resident #84 included but not limited to *Vascular Dementia with behavior disturbances. Resident #84's MDS with an Assessment Reference Date (ARD) of 03/08/19 coded resident with a BIMS score of 02 out of a possible 15 indicating severe cognitive impairment. In addition, the MDS with an ARD of 03/08/19, under section E (Behaviors), coded Resident #84 for exhibiting physical and verbal behaviors directed towards others 1-3 days each week. The resident was also coded for other behaviors symptoms not directed toward others. Under section (E0800), for rejection of care was coded the behavior occurred 1-3 days each week and under section (E0900), for wandering was coded for this type behavior occurring daily. Resident #84's comprehensive care plan documented resident at risk for side effects related to use of psychoactive medications. Some of the goals set for the resident included not but not limited to: will achieve desired effect from ordered medications, and will have no negative effects from medication use as ordered. Some of the intervention to manage the resident's goal include observing and reporting signs/symptoms of tardive dyskinesia, complete AIMS per facility policy, consult and coordinate care with mental health professional per physician order and Consulting Pharmacist Medication Regimen Review at least monthly. The physician Order Sheet (POS) for April 2019 included the following orders: 1. Ativan 0.5 mg tablet by mouth as needed every 8 hours starting on 03/03/19 for the following target behaviors: inconsolable restlessness, physically abusive, agitation, combativeness and delusion. 2. Ativan 2 mg/ml injection solution-give 0.5 ml intramuscular as need every 6 hours if unable to take by mouth or sublingual starting on 03/08/19 for the following target behaviors: inconsolable restlessness, physically abusive, agitation, combativeness and delusion. The March 2019 Medication Administration Records (MAR's) evidenced documentation that the resident was administered the PRN Ativan 0.5 mg by mouth on the following days: 03/22/19 at 11:18 a.m., 03/28/19 at 10:34 p.m., and 03/29/19 at 11:43 p.m. The April 2019 Medication Administration Records (MAR's) evidenced documentation that the resident was administered the PRN Ativan 0.5 ml (IM) on 03/27/19 at 9:25 p.m. Review of Resident #84's Physician Progress note dated 03/26/19 include the following: -Nature of Presenting Problem: First 30-day recertification and review of chronic illness and comorbidity. -History of Present Illness include but not limited to resident has dementia with history of behaviors that include combativeness. No recent behaviors note since last exam. -All medications reviewed during today's visit. The physician last saw resident #84 on 03/18/19 prior to his current visit on 03/26/19. An interview was conducted with the Director of Nursing (DON) on 04/18/19 at approximately 4:55 p.m. The DON stated, I was aware the PRN antipsychotic medication was good for only 14 days then must be re-evaluated but not the psychotropic. He said the PRN psychotropic are not being re-evaluated after 14 days. The facility administration was informed of the finding during a briefing on 04/18/19 at approximately 5:25 p.m. The facility did not present any further information about the findings. The facility policy titled Virginia Health Services (VHS) Standing Orders (Revised on 12/15/17) did not include antipsychotropic medications prescribed on a PRN basis are limited to 14 days without documenting the rational and duration on the residents medical record. Definitions: *Vascular dementia is a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain (https://www.mayoclinic.org/diseases-conditions/vascular-dementia/symptoms). *Ativan is used to relieve anxiety (www.nlm.nih.gov/medlineplus/druginfo/meds/a682053.html).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on general observation of the nursing facility, staff interviews, the facility failed to ensure medications were stored in accordance with currently accepted professional principles in 1 out of 9 facility medication carts. The facility staff failed to ensure one eye drop (Latanoprost) was removed from medication cart once expired on Unit (M). The eye drops in its original box had an open date of 03/04/19 with a do not use date after 04/04/19. The findings included: Resident #41 was originally admitted to the facility on [DATE]. Diagnosis for Resident #41 included but not limited to *Glaucoma. Resident #41's Minimum Data Set (an assessment protocol) with an Assessment Reference Date (ARD) of 02/07/19 coded Resident #41 with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. On 04/18/19 at approximately 1:35 p.m., the medication cart on Unit (M) with License Practical Nurse (LPN) #2 was inspected. During the inspection of the medication cart the eye drops (Lantanoprost) was observed in the cart. The eye drops were stored in its original box. Written on the box was an open date of 03/04/19 with a do not use after 04/04/19. The surveyor asked LPN #2, How long is the eye drop (Latanoprost solution 0.005%) good for once opened. The LPN stated, It is good for 30 after being open. The surveyor asked, Should the eye drops still be stored inside the medication cart after the expiration time has lapsed she replied, Absolutely not, it should not be on the medication cart past 30 days after being opened. The LPN said the eye drops should have been removed the medication cart on 04/04/19. An interview was conducted with the Director of Nursing (DON) on 04/18/19 at approximately 5:02 p.m. The DON stated, All the nurses should be doing the 5 rights prior to administering a resident their medication. The DON said the charge nurse should be inspecting the medication cart daily behind the floor nurses as a double check. He said the charge nurse should catch any expired medications left on the medication cart. The facility administration was informed of the finding during a briefing on 04/18/19 at approximately 6:25 p.m. The facility did not present any further information about the findings. The facility's policy titled Medication Administration Guidelines (Revision date 09/08/17). -Medication Administration read in part: Prior to administration, the medication and dosage schedule on the MAR/TAR is compared with the medication label. If the medication is discontinued, outdated, or unusable, remove the medication for proper disposal. *How to store Latanoprost: After opening the bottle store it at room temperature (do not store above 25°C) and use within 4 weeks of opening. When you are not using Latanoprost, keep the bottle in the outer carton, in order to protect it from light (www.drugs.com). Definitions: *Latanoprost is used to treat high pressure inside the eye due to glaucoma (open angle type) or other eye diseases (e.g., ocular hypertension) (https://www.webmd.com/drugs). *Glaucoma is an eye disease associated with increased pressure within the eye. Glaucoma can damage the optic nerve and cause impaired vision and blindness (https://www.webmd.com/drugs).

Based on observations, clinical record review, staff and resident interview and facility document review, the facility staff failed to ensure the specialized rehabilitation services were provided for 1 of 46 residents (Resident #440) in the survey sample. Resident #440, a newly admitted stroke resident, had difficulty at times communicating her needs to the nursing staff (expressive aphasia). The facility staff failed to ensure speech therapy recommended the appropriate communication devices as needed and relayed information to the nursing staff. Failure to take these steps resulted in the nursing staff's failure to provide alternate communication devices to foster appropriate communication to and from the resident in order to avoid episodes of distress and frustration. The findings included: Resident #440 was admitted to the nursing facility on 4/12/19 with a diagnosis of atrial fibrillation and history of cerebral infarction (stroke) with left sided hemiplegia. The resident's Minimum Data Set (MDS) assessment was not due. The 48 hour baseline care plan dated 4/12/19-4/14/19 identified the resident had the potential for impaired quality of life related to a new environment and change in health status. The goal set by the staff for the resident indicated that the resident would not experience adverse effects for new admission or new environment. There were no approaches that addressed the resident's difficulty in communication in order to create and maintain a safe environment and psychological well-being. The care plan did not identify the stroke and any deficits she had as a result of past or current stroke with staff interventions and/or resident needs. The following observation was made of Resident #440 on 4/17/19 at 12:10 p.m.: Resident #440 was positioned in the doorway of her room in her wheelchair. She summoned the Certified Nursing Assistant (CNA) #1 and asked her what sounded like a couple of pictures. When the CNA could not understand her after several attempts, a second and third staff approached the resident due to the residents obvious distress. These persons were not able to understand the resident as she kept repeating the same phrase over and over a couple of pictures. The Unit Manager, Licensed Practical Nurse (LPN) #3 asked the resident several times to tell her what she wanted and the same phrase was repeated by the resident. The resident began stomping her feet, shaking her head from sided to side, hitting herself violently and screaming as loud as she could as she cried with tears streaming down her face. Three more times the CNA, Unit Manager and others surrounded the resident asking her what she wanted to no avail. CNA #1 pulled the resident into her room as the resident continued the same aforementioned behavior. The resident pointed to this surveyor with her right hand and motioned to come to her. Once the resident was approached she appeared to want what this surveyor was holding, a clip board, but no one was sure why. This surveyor asked the group, Does she use a communication board? The Unit Manager literally ran to the nurse's station and returned approximately 5 minutes later with a communication sheet and pointed to several pictured items and letters, but the resident continued with her frustrated behavior. The resident motioned again to this surveyor. The question was asked at this point, Does she write? One of the staff present retrieved a blank sheet of paper, gave it to her with a pen as the resident tried to write in cursive with the paper on her left thigh. No one could read the message the resident tried to write. Due to the resident's continued behaviors of screaming, crying, stomping and slapping herself, this surveyor came closer to the resident. The resident took the clipboard placed the paper on the clipboard and was prompted to print what she was trying to tell the staff. The resident printed very clearly, cowboy picture pointing to the television. CNA #1 immediately said, She wants the television channel to remain on the channel that has cowboys on it. As quickly as the extreme outburst began, it ended and the resident rose her right hand to high five everyone with smiles. CNA #1 said, Oh that's right, her daughter wrote it on a piece of paper and told us to keep the channel on 75 which is a cowboy channel. On 4/18/19 at 10:30 a.m., an interview was conducted with the speech therapist (ST). She stated the resident was screened and assessed on 4/15/19 with a new stroke, but had a history of previous stroke with some expressive aphasia per information from the resident's daughter. The ST stated she thought the most recent stroke resulted in left sided weakness. The ST evaluation dated 4/15/19 indicated the resident had severe impairment in articulation with moderate intelligibility, but the fluency was within normal limits meaning that she could put several words together. When the episode from 4/17/19 at 12:10 p.m. was explained to the ST, she stated the goal was to increase articulation, but when all else fails and the resident becomes frustrated, a pen and pad of paper was necessary in order to reduce frustration and have her needs met, as well as a communication board. When asked where this information was written because it was not in the ST screening evaluation, or how the information was relayed to the nursing staff she said, That is not what I do, the rehabilitation director would share that information with the nursing staff. On 4/18/19 at 12:15 p.m., the rehabilitation director stated the ST should have shared what the resident needed to communicate with the nursing staff in order to have her needs met. She also said during the morning meetings especially on the skilled unit where the resident resided results of screenings and evaluations are shared with nurse managers and the MDS nurse, along with reading the therapy notes, thus the care plan would reveal the need with goals and interventions. The ST stated it was her expectation that once the evaluation is completed, the charge nurse, therapy head and Director of Nursing (DON) be made aware of what is needed for patients care; in this case a communication board, paper and pen if able to write to avoid times of frustration when the resident cannot verbally communicate her needs. She stated once everything is completed, nursing will update the care plan. She presented a re-evaluation 4/18/19 at 3:15 p.m. that was conducted shortly after this interview that educated the resident on strategies on how to slow her speech rate, increase intensity and over exaggerate sounds to increase speech intelligibility. The evaluation included provision of communication board, pad and pen to increase communication wants and needs and that this was an alternative means to communication in case of communication breakdown. On 4/18/19 at approximately 5:00 p.m., an interview was conducted with the Administrator, the DON and the Assistant Director of Nursing Operations (ADNO). The DON stated even without any information from ST, he expected the nursing staff to have been able to handle the aforementioned situation and provide the resident with either a communication tool or pad and pencil. The Administrator stated, I think that situation could have definitely been handled better for the resident's sake as well as safety. During the debriefing with the Administrator, DON and ADNO on 4/18/19 at approximately 6:00 p.m., no further information was provided prior to survey exit. The policy and procedures titled Specialized Rehabilitation Services dated 4/6/05 indicated the facility will obtain and provide appropriate services if residents require specialized rehabilitative services such as physical therapy, speech-language pathology, occupational therapy and health rehabilitation services for mental illness and mental retardation as required in the resident's comprehensive plan of care.

Based on observation, staff interviews, facility documentation review the facility failed to implement appropriate infection control practices during medication administration for 1 (Resident #42) of 46 residents in the survey sample. The facility staff failed to discard a pill that was dropped on Resident #42's bed during medication observation. The License Practical Nurse (LPN) placed the pill in the resident's left hand; the pill fell on the residents bed. The nurse retrieved the pill off of the bed with her bare hand and placed the pill in the resident's left hand. Resident #42 consumed the pill with a sip of water. The findings included: Resident #42's current Minimum Data Set (MDS), an admission assessment with an Assessment Reference Date (ARD) of 02/08/19 coded the resident a 10 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) that indicated moderate cognitive impairment. During the medication observation on 04/16/19 at approximately 4:28 p.m. LPN #1 pulled the following medications from the medication cart for Resident #42: Aspirin 81 mg (milligram)tablet, Magnesium oxide 400 mg tablet and Metoprolol 100 mg. The LPN went to Resident #42's bedside, elevated the head of the bed, then placed all three pills in the residents hand. The resident turned her hand to the side and her Metroprolol fell out of her hand, falling on her bed landing at her left side. The LPN searched the resident's bed by using her right hand feeling for the missing pill under the resident's left side; the LPN was not wearing gloves. The LPN removed the pill from the bed using her bare hand, placed the pill in the resident's left hand, then the resident took the pill. The resident replied, That little pill drops out of my hand all the time. A phone interview conducted with LPN #1 on 4/18/19 at 1:43 p.m. The surveyor asked, What should you have been done with the pill once it was dropped in the resident's bed doing the medication observation on 04/18/19 at 4:28 p.m.,with this surveyor. The LPN stated, I'm not really sure, I do not have an answer. The LPN stated, Should I have done something else, I did not realize giving the resident her pill after it was dropped in the bed was wrong. An interview was conducted with the Director of Nursing (DON) on 04/18/19 at approximately 2:33 p.m. The surveyor asked, What is your expectations for your nurses if they drop a pill in the resident's bed while doing their medication pass. The DON stated, I expect for the nurse to discard the medication, use hand sanitizer then pull another pill to be administered. The facility administration was informed of the finding during a briefing on 04/18/19 at approximately 6:25 p.m. The facility did not present any further information about the findings. The facility's policy titled Infection Control-Hand Hygiene (Revision 03/22/18). Policy: Healthcare workers are to use effective hand hygiene frequently to help prevent the spread of microorganisms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility staff failed to send Resident #106's care plan summary to the receiving facility when discharged to the hospital on [DATE]. Resident #106 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, Multiple Sclerosis, Quadriplegia and Hypertension. Resident #106's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 03/23/2019 coded Resident #106 with a BIMS (Brief Interview for Mental Status) score of 14 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #106 as requiring total assistance with Activities of Daily Living. On 04/18/2019 at 5:20 p.m., an interview was conducted with the Director of Nursing (DON). The DON was asked, Was Resident #106's care plan summary sent to the hospital upon discharge? The DON stated, No, there is no documentation to support that it was sent. The DON stated, Nursing usually sends a Transfer Clinical Summary with residents when transferring them to the hospital which includes the care plan and Bed Hold Notice. However, there is no documentation stating that it was sent. The administrative team was informed of the finding on 04/18/2019 at approximately 6:30 p.m. No further information was provided about the finding. 6. Resident #50 was originally admitted to the facility on [DATE]. The resident was re-admitted to the facility on [DATE] and 01/08/19. Diagnosis for Resident #50 included but not limited to *Dementia and *Type II Diabetes. Resident #50's current Minimum Data Set (MDS), a significant change with an Assessment Reference Date (ARD) of 02/14/19 coded the resident with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. The Discharge MDS assessment dated [DATE] - discharge return anticipated, resident re-admitted on [DATE]. The Discharge MDS assessment dated [DATE]- discharge return anticipated, resident re-admitted on [DATE]. On 11/25/18 at approximately 3:31 a.m., according to the facility's documentation, Per order from the on call Physician Assistant (PA), new order obtained to send Resident #50 to the local emergency room (ER) for a critical lab Sodium level of 169. Resident #50 was re-admitted to the nursing facility on 11/29/18. On 01/03/19 at approximately 3:03 p.m., according to the facility's documentation, Nurse Practitioner (NP) in to assess resident with new orders to send to local ER after speaking to daughter to see what she decides. The daughter wanted to send Resident #50 to the ER. The daughter has declined hospice at this time. The resident was transported to the local ER via Life Care transportation. Resident #50 was re-admitted to the nursing facility on 01/08/19. An interview was conducted with the Administrator and Director of Nursing (DON) on 04/18/19 at approximately 5:00 p.m. The DON said he was unable to locate documentation in Resident #50's clinical record that the care plan summary was sent when discharged to the hospital on [DATE] and 01/03/19. The DON said when a resident is transferred to the hospital; the nurse will complete a checklist in the computer that will prompt the nurse to check the care plan summary for that resident. The checklist is converted into a Transfer Clinical Summary. The Transfer Clinical Summary if completed correctly will include the residents current care plan with the their problems and care plan goals. The DON stated, Since, we were unable to locate documentation in the residents clinical record, I cannot say the residents care plan summary was sent with Resident #50 when discharged to the hospital on [DATE] and 01/03/19. The facility administration was informed of the finding during a briefing on 04/18/19 at approximately 6:25 p.m. The facility did not present any further information about the findings. The facility's policy titled Admission, Transfer & Discharge Rights Policy (Last revision date: 01/25/17). Definitions: *Dementia is the name for a group of symptoms caused by disorders that affect the brain. People with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose their ability to solve problems or control their emotions. Their personalities may change. They may become agitated or see things that are not there (https://medlineplus.gov/ency/article/007365.htm). *Diabetes Mellitus Type II is a lifelong (chronic) disease in which there is a high level of sugar (glucose) in the blood (https://medlineplus.gov/ency/article/007365.htm). Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to convey the summary of goals of the comprehensive plan of care upon transfer/discharge for 6 of 46 residents (Resident #134, #52, #81, #80, #106 and #50) in the survey sample. 1. The facility staff failed to include in the transfer summary indication that the facility staff conveyed to the receiving provider the resident's comprehensive care plan goals at the time of discharge to the local hospital on 3/8/19 and 3/28/19 or as soon as possible to the actual time of transfer for Resident #134. 2. The facility staff failed to include in the transfer summary indication that the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge to the local hospital on 2/8/19 or as soon as possible to the actual time of transfer for Resident #52. 3. The facility staff failed to include in the transfer summary indication that the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge to the local hospital on 3/15/19 and emergency department on 3/20/19 or as soon as possible to the actual time of transfer for Resident #81. 4. The facility staff failed to include in the transfer summary indication that the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge to the local hospital on 4/6/18 and on 5/22/18 or as soon as possible to the actual time of transfer for Resident #80. 5. The facility staff failed to send Resident #106's care plan summary to the receiving facility when discharged to the hospital on [DATE]. 6. The facility staff failed to ensure that Resident #50's Plan of Care Summary to include care plan goals, was sent upon transfer/discharge to the hospital on [DATE] and 2/3/19 The findings include: 1. The facility staff failed to include in the transfer summary indication that the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge to the local hospital on 3/8/19 and 3/28/19 or as soon as possible to the actual time of transfer for Resident #134. Resident #134 was admitted to the nursing facility on 12/5/05 with diagnoses that included adult failure to thrive, fractured right tibia and high blood pressure. Resident #134's most recent Minimum Data Set (MDS) assessment was a significant change in status assessment dated [DATE] and coded the resident with a score of 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was fully intact in the cognitive skills necessary for daily decision making. The nurse's notes dated 3/8/19 indicated the resident fell on the floor and complained of pain in her right knee. Based on continued complaints of pain, the resident was transported to the ED and admitted to the hospital on [DATE]. Resident #134 was readmitted to the nursing facility on 3/30/19. There was no documentation in the clinical record that facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge or soon thereafter to the local hospital. The nurse's notes dated 3/28/19 indicated the resident was transported to the local hospital for surgery. Resident #134 was readmitted to the nursing facility on 3/30/19. There was no documentation in the clinical record that facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge or soon thereafter to the local hospital. On 4/18/19 at 1:10 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #3. She stated she sent transfer paperwork, but the paperwork did not include a care plan summary. On 4/18/19 at approximately 5:00 p.m., the Administrator and Director of Nursing (DON) stated that could not provide evidence that the care plan summary was sent to the hospital. They said, When a resident is transferred to the ER or the hospital the nurse is prompted through a check list in the computer for the specific resident that in turn generates the transfer summary that includes the care plan summary with goals as well as the bed hold notice, but there is no way to confirm the documents was sent at the time of the transfer or that it was sent over to the ED or hospital soon after. We had in-services that instructed the nurse to document in the nurse's notes the summaries and bed hold notices were sent. We actually see some nurses are documenting but others are not and there is a lack of consistency. We will continue to re-educate all our nurses. The Administrator or DON did not present any additional documentation prior to survey exit on 4/18/19 at 7:00 p.m. 2. The facility staff failed to include in the transfer summary indication that the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge to the local hospital on 2/8/19 or as soon as possible to the actual time of transfer for Resident #52. Resident #52 was admitted to the nursing facility on 12/6/17 with diagnoses that included chronic kidney disease with hemodialysis, left kidney malignant neoplasm, high blood pressure stroke. The resident's most recent Minimum Data Set (MDS) assessment was a significant change in status assessment dated [DATE] and coded the resident with a score of 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was fully intact in the skills necessary for daily decision making. The nurse's notes dated 2/8/09 indicated the resident was being sent to the local emergency department (ED) from the dialysis center. The resident returned to the nursing facility on 2/13/19. There was no evidence that the care plan summary was forwarded to the local hospital on 2/8/19 or as soon as possible thereafter. On 4/18/19 at approximately 5:00 p.m., the Administrator and Director of Nursing (DON) stated that could not provide evidence that the care plan summary was sent to the hospital. They said, When a resident is transferred to the ER or the hospital the nurse is prompted through a check list in the computer for the specific resident that in turn generates the transfer summary that includes the care plan summary with goals as well as the bed hold notice, but there is no way to confirm the documents was sent at the time of the transfer or that it was sent over to the ED or hospital soon after. We had in-services that instructed the nurse to document in the nurse's notes the summaries and bed hold notices were sent. We actually see some nurses are documenting but others are not and there is a lack of consistency. We will continue to re-educate all our nurses. They added that they would have to make sure when residents are sent to the ED and or admitted to the hospital from a doctors office or dialysis, the transfer summaries are sent over that included the same aforementioned information. The Administrator or DON did not present any additional documentation prior to survey exit on 4/18/19 at 7:00 p.m. 3. The facility staff failed to include in the transfer summary indication that the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge to the local hospital on 3/15/19 and emergency department on 3/20/19 or as soon as possible to the actual time of transfer for Resident #81. Resident #81 was admitted to the nursing facility on 3/1/19 with diagnoses that included stroke, pathological fracture and high blood pressure. The resident's most recent Minimum Data Set (MDS) assessment was an admission assessment and coded the resident with a score of 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was fully intact in the skills necessary for daily decision making. The nurse's notes dated 3/15/19 indicated Resident #81 was transferred to the local emergency department and admitted to the hospital for blood in the urine, pain and burning sensation. The resident was readmitted to the nursing facility on 3/16/19. There was no evidence that the care plan summary was forwarded to the local hospital on 3/15/19 or as soon as possible thereafter. The nurse's notes dated 3/20/19 indicated Resident #81 was transferred to the local ED due to replacement of indwelling urinary catheter. The resident returned to the nursing facility on 3/20/19. There was no evidence that the care plan summary was forwarded to the local hospital on 3/20/19 or as soon as possible thereafter. On 4/18/19 at approximately 5:00 p.m., the Administrator and Director of Nursing (DON) stated that could not provide evidence that the care plan summary was sent to the hospital. They said, When a resident is transferred to the ER or the hospital the nurse is prompted through a check list in the computer for the specific resident that in turn generates the transfer summary that includes the care plan summary with goals as well as the bed hold notice, but there is no way to confirm the documents was sent at the time of the transfer or that it was sent over to the ED or hospital soon after. We had in-services that instructed the nurse to document in the nurse's notes the summaries and bed hold notices were sent. We actually see some nurses are documenting but others are not and there is a lack of consistency. We will continue to re-educate all our nurses. The Administrator or DON did not present any additional documentation prior to survey exit on 4/18/19 at 7:00 p.m. 4. The facility staff failed to include in the transfer summary indication that the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge to the local hospital on 4/6/18 and on 5/22/18 or as soon as possible to the actual time of transfer for Resident #80. Resident #80 was admitted to the nursing facility on 3/16/18 with diagnoses that included kidney failure, atrial fibrillation, pressure ulcers, stroke and peripheral vascular disease (PVD). The resident's most recent Minimum Data Set (MDS) assessment was an admission assessment and coded the resident with a score of 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was fully intact in the skills necessary for daily decision making. Resident #80 was admitted to the local hospital on 4/6/18 and readmitted to the nursing facility on 4/10/18. There was no evidence that the care plan summary was forwarded to the local hospital on 4/6/19 or as soon as possible thereafter. Resident #80 was admitted to the local hospital on 5/22/19 and readmitted to the nursing facility on 5/29/18. There was no evidence that the care plan summary was forwarded to the local hospital on 5/22/19 or as soon as possible thereafter. On 4/18/19 at approximately 5:00 p.m., the Administrator and Director of Nursing (DON) stated that could not provide evidence that the care plan summary was sent to the hospital. They said, When a resident is transferred to the ER or the hospital the nurse is prompted through a check list in the computer for the specific resident that in turn generates the transfer summary that includes the care plan summary with goals as well as the bed hold notice, but there is no way to confirm the documents was sent at the time of the transfer or that it was sent over to the ED or hospital soon after. We had in-services that instructed the nurse to document in the nurse's notes the summaries and bed hold notices were sent. We actually see some nurses are documenting but others are not and there is a lack of consistency. We will continue to re-educate all our nurses. The Administrator or DON did not present any additional documentation prior to survey exit on 4/18/19 at 7:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #106 was discharged to the hospital on [DATE] and the facility staff failed to provide the Resident and/or Resident Representative a written Bed Hold Notice. Resident #106 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, Multiple Sclerosis, Quadriplegia and Hypertension. Resident #106's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 03/23/2019 coded Resident #106 with a BIMS (Brief Interview for Mental Status) score of 14 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #106 as requiring total assistance with Activities of Daily Living. On 04/18/2019 at 5:20 p.m., an interview was conducted with the Director of Nursing (DON). The DON was asked, Can you provide documentation that a Bed Hold Notice was issued to Resident #106 or the resident's representative upon discharge to the hospital? The DON stated, No, there is no documentation to support that it was provided. The DON stated, Nursing usually sends a Transfer Clinical Summary with residents when transferring to the hospital which includes the care plan and Bed Hold Notice. However, there is no documentation stating that it was sent. The administrative team was informed of the finding on 04/18/2019 at approximately 6:30 p.m. No further information was provided about the finding. 6. Resident #54 was discharged to the hospital on [DATE] and the facility staff failed to provide the Resident and/or Resident Representative a written Bed Hold Notice. Resident #54 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, Heart Failure and Diabetes Mellitus. Resident #54's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 02/18/2019 coded Resident #54 with a BIMS (Brief Interview for Mental Status) score of 4 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #54 as requiring extensive assistance of 2 with bed mobility, extensive assistance of 1 with eating and personal hygiene, and total dependence of 2 with transfer and toilet use. On 04/18/2019 at 5:20 p.m., an interview was conducted with the Director of Nursing (DON) and he was asked, Can you provide documentation that a Bed Hold Notice was issued to Resident #54 or the Resident's Representative upon discharge to the hospital? The DON stated, No, there is no documentation. The DON was asked, Was a Bed hold Notice issued to Resident #54 or the Resident's Representative upon discharge to the hospital? The DON stated, No, it was not. The DON was asked, Should a written Bed Hold Notice be issued to the Resident and /or Resident Representative upon discharge? The DON stated, Yes. On 04/19/2019 at approximately 6:30 p.m., at the pre-exit meeting the Administrator and the Director of Nursing was informed of the findings. The facility did not present any further information about the findings. 7. The facility staff failed to ensure that Resident #50 was provided a written copy of the facility's bed-hold and reserve bed payment policy upon transfer/discharge to the hospital on [DATE] and 2/3/19. Resident #50 was originally admitted to the facility on [DATE]. The resident was re-admitted on [DATE] and 01/08/19. Diagnosis for Resident #50 included but not limited to *Dementia and *Type II Diabetes. Resident #50's current Minimum Data Set (MDS), a significant change with an Assessment Reference Date (ARD) of 02/14/19 coded the resident with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. The Discharge MDS assessment dated [DATE]-discharge return anticipated, resident re-admitted on [DATE]. The Discharge MDS assessment dated [DATE]-discharge return anticipated, resident re-admitted on [DATE]. On 11/25/18 at approximately 3:31 a.m., according to the facility's documentation, Per order from the on call Physician Assistant (PA), new order obtained to send Resident #50 to the local emergency room (ER) for a critical lab Sodium level of 169. Resident #50 was re-admitted to the nursing facility on 11/29/18. On 01/03/19 at approximately 3:03 p.m., according to the facility's documentation, Nurse Practitioner (NP) in to assess resident with new orders to send to local ER after speaking to daughter to see what she decides. The daughter wanted to send Resident #50 to the ER. The daughter has declined hospice at this time. The resident was transported to the local ER via (Name of Company) transportation. Resident #50 was re-admitted to the nursing facility on 01/08/19. An interview was conducted with the Administrator and Director of Nursing (DON) on 04/18/19 at approximately 5:00 p.m. The DON said he was unable to locate documentation in Resident #50's clinical record that the bed hold policy was sent when discharged to the hospital on [DATE] and 01/03/19. The DON said when a resident is transferred to the hospital; the nurse will complete a checklist in the computer that will prompt the nurse to check the bed hold policy notice for that resident. The checklist is converted into a Transfer Clinical Summary. The Transfer Clinical Summary if completed correctly will include the bed hold policy notice but the nurses must document the bed hold policy was sent when discharged to the hospital in their clinical record. The DON stated, Since, we were unable to locate documentation in Resident #50's clinical record, I cannot say the bed hold policy was sent with Resident #50 when discharged to the hospital on [DATE] and 01/03/19. The facility administration was informed of the finding during a briefing on 04/18/19 at approximately 6:25 p.m. The facility did not present any further information about the findings. The facility's policy titled Admission, Transfer & Discharge Right Policy revised (01/25/17). Notice of bed-hold policy and return. If a resident requires transfer to an acute hospital, the facility will offer the resident the opportunity of electing to have the bed held. Definitions: *Dementia is the name for a group of symptoms caused by disorders that affect the brain. People with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose their ability to solve problems or control their emotions. Their personalities may change. They may become agitated or see things that are not there (https://medlineplus.gov/ency/article/007365.htm). *Diabetes Mellitus Type II is a lifelong (chronic) disease in which there is a high level of sugar (glucose) in the blood (https://medlineplus.gov/ency/article/007365.htm). Based on clinical record review, staff and resident interviews, and facility documentation, the facility staff failed to issue a written notice of the bed hold policy upon transfer to the local hospital for 7 of 46 residents (R #134, #52, #81, #80, #106, #54 and #50) in the survey sample. 1. The facility staff failed to ensure Resident #134 or Resident Representative (RR) was issued a written notice of the bed hold reserve policy upon transfer to the local hospital on 3/8/19 and on 3/28/19. 2. The facility staff failed to ensure Resident #52 or RR was issued a written notice of the bed hold policy upon transfer to the local hospital on 2/8/19. 3. The facility staff failed to ensure Resident #81 or RR was issued a written notice of the bed hold policy upon transfer to the local hospital on 3/15/19 and to the emergency department (ED) on 3/20/19. 4. The facility staff failed to ensure Resident #80 or RR was issued a written notice of the bed hold policy upon transfer to the local hospital on 4/6/18 and on 5/22/18. 5. Resident #106 was discharged to the hospital on [DATE] and the facility staff failed to provide the Resident and/or Resident Representative a written Bed Hold Notice. 6. Resident #54 was discharged to the hospital on [DATE] and the facility staff failed to provide the Resident and/or Resident Representative a written Bed Hold Notice. 7. The facility staff failed to ensure that Resident #50 was provided a written copy of the facility's bed-hold and reserve bed payment policy upon transfer/discharge to the hospital on [DATE] and 2/3/19. The findings include: 1. The facility staff failed to ensure Resident #134 or Resident Representative (RR) was issued a written notice of the bed hold reserve policy upon transfer to the local hospital on 3/8/19 and on 3/28/19. Resident #134 was admitted to the nursing facility on 12/5/05 with diagnoses that included adult failure to thrive, fractured right tibia and high blood pressure. Resident #134's most recent Minimum Data Set (MDS) assessment was a significant change in status assessment dated [DATE] and coded the resident with a score of 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was fully intact in the cognitive skills necessary for daily decision making. The nurse's notes dated 3/8/19 indicated the resident fell on the floor and complained of pain in her right knee. Based on continued complaints of pain, the resident was transported to the ED and admitted to the hospital on [DATE]. Resident #134 was readmitted to the nursing facility on 3/30/19. There was no documentation in the clinical record that the bed hold notice was issued to the resident or RR at the time of any of the transfers or discharges. The nurse's notes dated 3/28/19 indicated the transported to the local hospital for surgery. Resident #134 was readmitted to the nursing facility on 3/30/19. There was no documentation in the clinical record that the bed hold notice was issued to the resident or RR at the time of transfer or discharge from the facility. On 4/18/19 at 1:10 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #3. She stated she sent transfer paperwork, but the paperwork did not include a notice of the bed hold reserve policy. On 4/18/19 at 1:45 p.m., an interview was conducted with Resident #134. The resident stated she was not given any paperwork about the facility's bed hold policy when she was sent out to the hospital. On 4/18/19 at approximately 5:00 p.m., the Administrator and Director of Nursing (DON) stated When a resident is transferred to the ER or the hospital the nurse is prompted through a check list in the computer for the specific resident that in turn generates the transfer summary that includes the care plan summary with goals as well as the bed hold notice, but there is no way to confirm the documents was sent at the time of the transfer or that it was sent over to the ED or hospital soon after. We had in-services that instructed the nurse to document in the nurse's notes the summaries and bed hold notices were sent. We actually see some nurses are documenting but others are not and there is a lack of consistency. We will continue to re-educate all our nurses. The Administrator or DON did not present any additional documentation prior to survey exit on 4/18/19 at 7:00 p.m. 2. The facility staff failed to ensure Resident #52 or RR was issued a written notice of the bed hold policy upon transfer to the local hospital on 2/8/19. Resident #52 was admitted to the nursing facility on 12/6/17 with diagnoses that included chronic kidney disease with hemodialysis, left kidney malignant neoplasm, high blood pressure stroke. The resident's most recent Minimum Data Set (MDS) assessment was a significant change in status assessment dated [DATE] and coded the resident with a score of 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was fully intact in the skills necessary for daily decision making. The nurse's notes dated 2/8/09 indicated the resident was being sent to the local emergency department (ED) from the dialysis center. The resident returned to the nursing facility on 2/13/19. There was no evidence that the bed hold notice was issued to the resident or the RR at the time of transfer or discharge from the nursing facility. On 4/18/19 at approximately 5:00 p.m., the Administrator and Director of Nursing (DON) stated that When a resident is transferred to the ER or the hospital the nurse is prompted through a check list in the computer for the specific resident that in turn generates the transfer summary that includes the care plan summary with goals as well as the bed hold notice, but there is no way to confirm the documents was sent at the time of the transfer or that it was sent over to the ED or hospital soon after. We had in-services that instructed the nurse to document in the nurse's notes the summaries and bed hold notices were sent. We actually see some nurses are documenting but others are not and there is a lack of consistency. We will continue to re-educate all our nurses. They added that they would have to make sure when residents are sent to the ED and or admitted to the hospital from a doctors office or dialysis, the transfer summaries are sent over that included the same aforementioned information. The Administrator or DON did not present any additional documentation prior to survey exit on 4/18/19 at 7:00 p.m. 3. The facility staff failed to ensure Resident #81 or RR was issued a written notice of the bed hold policy upon transfer to the local hospital on 3/15/19 and to the emergency department (ED) on 3/20/19. Resident #81 was admitted to the nursing facility on 3/1/19 with diagnoses that included stroke, pathological fracture and high blood pressure. The resident's most recent Minimum Data Set (MDS) assessment was an admission and coded the resident with a score of 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was fully intact in the skills necessary for daily decision making. The nurse's notes dated 3/15/19 indicated Resident #81 was transferred to the local emergency department and admitted to the hospital for blood in the urine, pain and burning sensation. The resident was readmitted to the nursing facility on 3/16/19. There was no evidence that the bed hold notice was issued to the resident or the RR at the time of transfer from the nursing facility. The nurse's notes dated 3/20/19 indicated Resident #81 was transferred to the local ED due to replacement of indwelling urinary catheter. The resident returned to the nursing facility on 3/20/19. There was no evidence that the bed hold notice was issued to the resident or the RR at the time of transfer from the nursing facility. On 4/17/19 at 10:10 a.m., Resident #81 was asked if he was issued bed hold reserve policy at the time of any of his transfers or discharges to the local hospital. The resident responded that he was his own power of attorney and would be the one to get any paperwork, but did not believe he was given bed hold notices. On 4/18/19 at approximately 5:00 p.m., the Administrator and Director of Nursing (DON) stated When a resident is transferred to the ER or the hospital the nurse is prompted through a check list in the computer for the specific resident that in turn generates the transfer summary that includes the care plan summary with goals as well as the bed hold notice, but there is no way to confirm the documents was sent at the time of the transfer or that it was sent over to the ED or hospital soon after. We had in-services that instructed the nurse to document in the nurse's notes the summaries and bed hold notices were sent. We actually see some nurses are documenting but others are not and there is a lack of consistency. We will continue to re-educate all our nurses. They added that they would have to make sure when residents are sent to the ED and or admitted to the hospital from a doctors office or dialysis, the transfer summaries are sent over that included the same aforementioned information. The Administrator or DON did not present any additional documentation prior to survey exit on 4/18/19 at 7:00 p.m. 4. The facility staff failed to ensure Resident #80 or RR was issued a written notice of the bed hold policy upon transfer to the local hospital on 4/6/18 and on 5/22/18. Resident #80 was admitted to the nursing facility on 3/16/18 with diagnoses that included kidney failure, atrial fibrillation, pressure ulcers, stroke and peripheral vascular disease (PVD). The resident's most recent Minimum Data Set (MDS) assessment was an admission and coded the resident with a score of 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was fully intact in the skills necessary for daily decision making. Resident #80 was admitted to the local hospital on 4/6/18 and readmitted to the nursing facility on 4/10/18. There was no evidence that the bed hold notice was issued to the resident or the RR at the time of transfer from the nursing facility. Resident #80 was admitted to the local hospital on 5/22/19 and readmitted to the nursing facility on 5/29/18. There was no evidence that the bed hold notice was issued to the resident or the RR at the time of transfer from the nursing facility. On 4/18/19 at approximately 5:00 p.m., the Administrator and Director of Nursing (DON) stated When a resident is transferred to the ER or the hospital the nurse is prompted through a check list in the computer for the specific resident that in turn generates the transfer summary that includes the care plan summary with goals as well as the bed hold notice, but there is no way to confirm the documents was sent at the time of the transfer or that it was sent over to the ED or hospital soon after. We had in-services that instructed the nurse to document in the nurse's notes the summaries and bed hold notices were sent. We actually see some nurses are documenting but others are not and there is a lack of consistency. We will continue to re-educate all our nurses. The Administrator or DON did not present any additional documentation prior to survey exit on 4/18/19 at 7:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a complaint investigation, group interview and resident interviews, the facility staff failed to maintain an effective pest control program so that it is free of pests. The findings included: A complainant that involved Resident #80, a current resident, filed a complaint to the State survey and certification agency dated 3/4/19 that indicated cockroaches were seen in the resident's room, bathroom on the floors and ceilings. Although the complainant could not be reached via telephone, the resident was interviewable and stated during an interview on 4/17/19 at 8:50 a.m. that the complainant showed him the roaches that were in the bathroom and stated he had seen others in the room and throughout the facility. Resident #80 was admitted to the nursing facility on 3/16/18 with diagnoses that included kidney failure, high blood pressure history of stroke and left sided hemiplegia. Resident #80's most recent Minimum Data Set (MDS) assessment was a quarterly dated 3/6/19 and coded the resident with a score of 14 out of a possible 15 on the Brief Interview for Mental (BIMS) status which indicated the resident was intact with the cognitive skills for daily decision making. On 4/16/19 at 11:00 a.m., during the orientation tour, an interview was conducted with Resident #4. Resident #4 was admitted to the facility on [DATE]. Resident #4's current Minimum Data Set (MDS), a quarterly assessment with a date of 01/11/19 coded the resident with a score of 13 out of a possible 15 on the Brief Interview for Mental (BIMS) status which indicated no cognitive impairment with the skills for daily decision making. Resident #4 stated there were lots of roaches in the building, especially at night crawling under her bed. She stated she hoped the facility doors would not be shut, but she just wanted the surveyors to know in order to help get rid of the roaches. During the group meeting on 4/17/19 at 9:30 a.m. with five residents that represented several facility units stated there were large water bugs/roaches in the showers and were seen periodically throughout the building and they sure the facility had a company in to spray for bugs. Review of the pest control logs the pest control company routinely on a biweekly basis services the building's kitchen, doorways, corners, carpeted areas, soffits and storage area with the targeted pest, roaches. Some of the visits treatment is performed in resident bedrooms to include bathrooms. The GSM unit had recent monthly sightings by staff from February 2019 through April 2019. On 4/18/19 at approximately 5:00 p.m., the aforementioned resident concern about water bugs/roaches was shared with the Administrator. He stated he was aware of periodic problem areas, but they were treated by their current pest control company in addition to the biweekly treatments. At the exit conference, 4/18/19 at 6:30 p.m., the Administrator presented an infection control policy dated 4/12/18 that indicated a part of the prevention and control of infections was through pest control. No further information was provided prior to survey exit. Complaint Deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interviews the facility staff failed to maintain an infection control program to provide a safe, sanitary environment to prevent the development and transmission of disease and infection for 1 of 25 residents (Resident #17) and in the survey sample. The findings included: The facility staff failed to use a barrier and disinfect the over bed table after being used to check Resident #17's blood sugar and administering insulin. Resident #17 was originally admitted to the facility on [DATE]. Diagnoses for Resident #17 included but not limited to Type 2 Diabetes (1). Resident #17's Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/2017 coded the resident with a 09 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), moderate cognitive impairment. In addition, the MDS coded Resident #17 requiring total dependence of one with dressing and bathing, extensive assistance to two with transfers, extensive assistance of one with bed mobility, eating, toilet use and personal hygiene. Resident #17 was coded occasional incontinent of bowel and bladder. On 09/12/17 at approximately 4:35 p.m., during medication pass and pour, LPN #1 went to Resident #17's room caring a small white plastic basket containing alcohol pads, 2 x 2 gauzes, lancets, test strips and glucometer. LPN #1 placed the container on the over bed table; the table was noted to be without a barrier. The LPN cleaned resident's finger with an alcohol pad; pricked her finger with a lancet then placed the lancet on the over table. The LPN then used the glucometer to obtain the resident's blood sugar. After the blood sugar was obtained, the glucometer was placed on the over bed table. The LPN removed her gloves and put on another pair of gloves then injected 3 units of Humalog (2) insulin into her right upper arm. After the insulin injection, LPN #1 placed the used insulin syringe on the over bed table. The LPN removed all items off the over bed table and placed all supplies back into the medication cart. An interview was conducted with LPN #1 on 07/12/17 at approximately 4:30 p.m., who stated, I should have used a barrier on the over bed table and the table should have been wiped down after use. An interview was conducted with the Director of Nursing (DON) on 09/12/17 at approximately 5:05 p.m., who stated a barrier should have been used before putting the items used for the blood sugar checks and the table should have cleaned before and after use. The DON also stated, The used lancet should have been put in the sharps container and glucometer should not have been placed on the resident's over bed table after being used without the use of a barrier. The facility administration was informed of the finding during a briefing on 09/14/17 at 1:50 p.m. The facility did not present any further information about the findings.